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Digitized  by  the  Internet  Archive 

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http://www.archive.org/details/practicalmanualoOObrow 


PRACTICAL  MANUAL 


OF 


INSANITY 


MEDICAL  STUDENT  AND 
GENERAL  PRACTITIONER 


DANIEL  R.  BROWER,  A.M.,  M.D-,  LL.D* 

Professor  of  Nervous  and  Mental  Diseases  in  Rush   Medical  College,  in  Affili- 
ation with  the  University  of  Chicago  ;  Professor  of  Nervous  and  Mental 
Diseases  in  the  Woman's  Medical  School  of  the  Northwestern 
University,  and  in  the  Post-Graduate  Medical 
School  of  Chicago 


HENRY  M.  BANNISTER,  A.M.,  MJX 

Formerly  Senior  Assistant  Physician,  Illinois  Eastern  Hospital  for  the  Insane 


PHILADELPHIA   AND    LONDON 

W.  B,  SAUNDERS  &  COMPANY 
J  902 


Copyright,  1902, 
By  W.  B.  Saunders  &  Company 


PREFACE. 


It  is  the  aim  of  this  work  to  present  to  the  medical 
student  and  the  general  practitioner  the  essential  as- 
pects of  mental  disease  as  they  have  appeared  to  the 
authors.  It  is  hoped  that  it  will  be  found  to  give  an 
intelligible,  up-to-date  statement  of  the  leading  facts, 
and  one  that  will  be  serviceable  to  those  who  may  not 
be  able  to  give  the  time  for  any  more  exhaustive  studv. 
Psychiatry  is  a  large  subject,  and  it  is  impossible  for 
every  one  even  approximately  to  master  its  details ; 
but  no  graduate  in  medicine  should  be  unacquainted 
with  its  rudimentary  data  as  a  part  of  his  professional 
equipment. 

The  work  is  intended  as  a  handy  manual  for  students ; 
therefore  elaborate  case  records  and  pathologic  details, 
as  well  as  discussions  of  speculative  and  controverted 
questions,  are  necessarily  omitted.  To  make  it  the 
more  practical  and  useful,  certain  special  features  are 
included,  such  as  the  mention  of  the  forms  of  insanity 
not  usually  met  with  in  hospitals  for  the  insane,  a  com- 
parative table  of  classification,  and  a  chapter  on  some 
of  the  ethical  questions  relating  to  insanity  as  they  may 
arise  in  the  practice  of  medicine.  It  is  believed  that 
these  features  will  be  found  to  add  to  the  value  of  the 
work  to  the  student  and  general  practitioner. 

We  are  under  obligations  to  Drs.  James  C.  Gill  and 
Geo.  W.  Hall  for  valuable  assistance  in  proofreading 
and  otherwise. 


347529 


CONTENTS. 


CHAPTER  I.  page 

Definition  ;    Prevalence 1 1 

CHAPTER  II. 
Etiology   18 

CHAPTER  III. 
Pathology    4° 

CHAPTER  IV. 
General  Symptomatology  45 

CHAPTER  V. 
General  Symptomatology  {Continued) 62 

CHAPTER  VI. 
Course  and  Terminations 77 

CHAPTER  VII. 
General  Diagnosis  and  Prognosis 89 

CHAPTER  VIII. 
General    Therapeutics 100 

CHAPTER  IX. 
Classification   133 

CHAPTER  X. 
Acquired  Insanities 152 

CHAPTER  XI. 
Melancholia    185 

CHAPTER  XII. 
The  Toxic  Insanities 206 

CHAPTER  XIII. 
General  Paresis,  Paretic  Dementia 228 

CHAPTER  XIV. 
Organic  Insanity 255 

7 


0  CONTENTS. 

CHAPTER  XV.  page 

Insanities  of  the  Neuroses 259 

CHAPTER  XVI. 
Insanities  of  Critical  Periods 289 

CHAPTER  XVII. 
Degenerative  Insanities     314 

CHAPTER  XVIII. 
Degenerative  Insanities   (Continued)     342 

CHAPTER  XIX. 
Degenerative  Insanities  (Continued)     369 

CHAPTER  XX. 
Imbecility  and  Idiocy 377 

CHAPTER  XXI. 
Borderland  and  Episodic  States 390 

CHAPTER  XXII. 
Terminal  Dementia 405 

CHAPTER  XXIII. 
On  the  Examination  of  Persons  Supposed  to  be  Insane.  .  .   408 

CHAPTER  XXIV. 
The  Ethics  of  Insanity 413 


Index   421 


A 

PRACTICAL  MANUAL 

OF 

INSANITY. 


A  PRACTICAL  MANUAL 


INSANITY. 


CHAPTER  I. 
DEFINITION;  PREVALENCE. 

In  beginning  the  discussion  of  any  subject  it  is 
customary,  first,  to  define  it — that  is,  to  lay  down  its 
limits  and  to  state  in  concise  terms  its  special  and 
essential  features  as  a  definition.  In  some  of  the  more 
recent  treatises  on  insanity,  however,  this  custom  has 
apparently  come  to  be  recognized  as  more  honored  in 
the  breach  than  in  the  observance,  as  in  them  no 
attempt  is  made  at  a  special  preliminary  definition. 
To  give  a  perfectly  satisfactory  definition  of  insanity 
— one  that  gives  in  small  compass  all  its  salient  features 
and  omits  no  important  details — is  practically  impos- 
sible. In  a  most  elaborate  attempt  at  defining  in- 
sanity, Spitzka,  who  may  be  considered  as  most  com- 
petent, gives  half  a  page  to  the  definition  alone,  the 
necessary  glosses  and  qualifications  taking  up  over 
another  page.  This  can  hardly  be  called  a  brief  or 
concise  definition.  The  shorter  ones  that  have  been 
offered  are  all  open  to  criticism  in  one  respect  or 
another. 

The  difficulty  in  defining  insanity  lies,  in  the  first 
place,  in  the  fact  that  it  is  a  negative  proposition,  the 


12  INSANITY. 

prefix  in  making  it  so;  negatives  are  usually  difficult 
of  demonstration.  Insanity  is  opposed  to  sanity.  In 
order  to  define  insanity  it  is  necessary,  first,  to  deter- 
mine the  standard  of  sanity ;  this  is  not  a  fixed  quantity, 
but  depends  upon  many  conditions — first,  upon  what 
may  be  called  the  standard  of  the  environment,  which 
varies  not  only  with  every  stage  of  civilization  and 
barbarism,  but  also  with  each  social  station  and  each 
grade  or  phase  of  education.  What  would  be  natural 
and  commonplace  in  one  state  of  society  or  in  one 
community,  would  be  altogether  aberrant  and  unusual 
in  another,  and  this  difference  exists  even  in  the  same 
persons  under  various  circumstances.  This  environ- 
mental standard  varies  in  time  as  well  as  in  place,  in 
peoples  or  races,  or  in  differing  social  ranks — for  ex- 
ample, what  might  have  been  considered  normal  a 
century  or  two  ago,  might  be  evidence  of  mental  failure 
now.  Further,  as  helping  to  make  up  this  problem  of 
the  definition  of  sanity  and  insanity,  there  is  what 
might  be  called  the  standard  of  the  individual,  the 
shaping  of  which  is  begun  even  before  birth — in  inher- 
itance— and  is  not  completed  until  the  end  of  life. 
Every  one  thinks  and  acts  in  his  own  way,  and  thus 
there  is  formed  a  special  standard  of  normality,  which 
is  made  up  of  habits,  social  instincts,  education,  train- 
ing, and  more  especially  by  those  moral  traits  that 
constitute  what  we  call  character.  In  these  respects 
the  individual  must  be  compared  with  himself — he 
must  be  tested  by  what  he  ought  to  be  and  by  what  he 
was  in  his  normal  condition — before  an  accurate  de- 
cision can  be  arrived  at  in  any  case  of  suspected  mental 
disease.  As  a  rule,  this  is  not  difficult,  the  variations 
from  the  standard  of  environment  and  the  individual's 
normal  self  being  usually  so  patent  that  insanity  can 
be  recognized  almost  at  a  glance.  It  is  only  in  doubtful 
cases  that  comparisons  must  be  made  even  in  minute 
details  before  one  can  positively  assert  that  mental 


definition;  prevalence.  13 

derangement  exists ;  such  cases  occur  sufficiently  often 
to  make  the  recognition  of  these  factors  of  aliena- 
tion most  important.  There  are  no  hard-and-fast 
lines  separating  sanity  and  insanity,  and  it  is  this  that 
renders  a  precise  definition  almost,  if  not  quite,  an 
impossibility. 

Notwithstanding  this,  it  is  of  some  importance  to 
establish  a  clearly  stated,  albeit  an  imperfect,  definition 
of  insanity,  if  only  for  legal  purposes.  When  examin- 
ing a  medical  witness,  it  is  a  common  practice  for 
lawyers  to  ask  him  to  define  insanity;  his  inability  to 
do  this  may  affect  the  value  of  his  testimony.  Al- 
though, as  has  been  said,  a  rigidly  correct  medical 
definition  is  impossible,  one  that  will  fairly,  if  not  com- 
pletely, meet  the  legal  requirements,  which  is  its 
principal  utility,  may  still  be  offered.  The  medical 
concept  cannot  well  be  narrowed  down  to  the  limits 
of  a  brief  statement  and  yet  include  all  the  possibili- 
ties of  mental  derangement.  Even  if  we  follow  certain 
French  authors,  who,  like  Marce  and  Regis,  make  a 
distinction  between  mental  alienation  and  insanity, 
including  in  the  former  the  congenital  teratologic 
defects  and  the  transient  deliriums  and  intoxications, 
and  confine  the  term  insanity  to  the  acquired,  more  or 
less  permanent,  disordered  mental  conditions,  the  task 
is  but  little  lightened,  and  the  ground  is  still  too  exten- 
sive to  be  easily  covered.  All  definitions  heretofore 
attempted,  even  the  elaborate  one  of  Spitzka,  are 
open  to  many  objections:  they  are  inevitably  incom- 
plete, imperfect,  and  therefore  to  a  certain  extent 
misleading.  Insanity  is  especially  a  disease  or  derange- 
ment of  the  functions  of  the  cerebral  cortex,  and  this 
is  so  intimately  connected  with  every  other  bodily 
organ  and  function  that  it  is  easy  to  see  that  the  range 
of  its  symptoms  is  practically  infinite.  Its  definition^ 
being  of  necessity  incomplete,  must  be,  therefore, 
somewhat  indefinite;  it  is  useless  to  attempt  to  make 


14  INSANITY. 

it  comprehensive  or  exact.  We  cannot  specify  par- 
ticular pathognomonic  symptoms;  we  cannot  say 
with  Esquirol  that  it  is  afebrile,  or  with  Griesinger 
that  it  is  a  condition  in  which  a  true  appreciation  of 
the  facts  that  come  before  the  consciousness  is  impos- 
sible, or  with  a  much  more  recent  author  that  it  is  a 
disorder  characterized  by  a  more  or  less  permanent 
accidental  and  unconscious  disturbance  of  the  reason. 
All  these  are  but  partial  definitions ;  there  are  at  present 
markedly  febrile  forms  of  insanity  recognized,  there 
are  many  of  the  insane  who  fairly  appreciate  the  facts 
within  their  experience,  and  there  are  many  others  who 
are  more  or  less  fully  conscious  of  the  morbid  character 
of  their  feelings  and  of  the  fact  that  they  are  mentally 
deranged.  There  is  no  one  feature  that  is  pathogno- 
monic ;  insanity  is  a  general  and  a  protean  derangement 
of  the  mind.  A  definition  must  therefore  be  a  general 
one;  it  must  not  go  into  particulars,  but  must  merely 
broadly  outline  the  condition.  As  already  stated,  its 
chief  value  is  for  forensic  purposes;  the  law  demands 
a  definition,  and  the  partial  ones  that  have  satisfied 
lawyers  have  been  responsible  for  many  judicial 
murders  and  mistakes.  The  simplest  and  clearest 
possible  definition  is  therefore  the  best,  and  perhaps 
the  following  will  as  nearly  meet  the  demands  as  any : 
"Insanity  is  a  disease,  derangement,  or  defect  of  the 
brain,  causing  disordered  action  of  the  mind."  This 
has  the  advantage  of  stating  nothing  that  can  be 
disputed,  but  it  is  indefinite  and  covers  certain  condi- 
tions that  are  not  always  included  in  the  popular  or 
possibly  the  legal  conception  of  insanity.  If  it  is 
desired  to  make  the  distinction  between  mental 
alienation  in  general  and  insanity  proper  that  is  made 
by  some  authorities, — notably  Marce  and  Regis, — 
excluding  from  the  latter  certain  aberrant  mental  con- 
ditions, idiocy,  and  temporary  intoxications  and 
delirium  that  are  not  commonly  included  in  the  con- 


definition;  prevalence.  15 

cept,  this  definition  may  be  modified  by  inserting  the 
words  "more  or  less  permanent,"  making  it  read, 
"Insanity  is  a  more  or  less  permanent  disease  or  de- 
rangement of  the  brain  producing  disordered  action  of 
the  mind."  If  it  is  thought  advantageous  to  carry 
the  definition  a  little  further,  and  to  indicate  how  the 
mental  disorder  affects  the  individual  and  his  conduct, 
it  may  be  supplemented  by  the  statement  that  it  puts 
the  subject  into  a  condition  aberrant  to  his  normal 
self  and  out  of  relation  to  his  environment.  An  im- 
becile is  a  subject  of  mental  alienation,  but  he  may 
fit  into  a  niche  in  society  and  to  a  certain  extent 
harmonize  with  his  surroundings.  But  he  may  also, 
as  Regis  says,  be  the  victim  of  an  attack  of  mania 
superimposed  upon  his  existing  mental  deficiencies, 
and  then  he  is  in  the  restricted  sense  of  the  word  a 
lunatic.  In  the  same  way  we  make  a  distinction  be- 
tween the  effects  of  intoxicants,  which  practically 
derange  the  cerebral  function  as  much  as  does  an 
attack  of  insanity,  and  the  insanity  itself,  on  account 
of  their  transitory  and  generally  voluntary  character. 
The  sympathetic  delirium  of  febrile  diseases  is  also 
excluded  for  similar  reasons.  Practically  they  all  fall 
under  the  general  category  of  mental  derangement  or 
defect,  but  the  customary  and  the  legal  distinctions 
must  be  borne  in  mind. 

As  a  definition  of  insanity,  therefore,  we  may  offer: 
"Insanity  is  a  more  or  less  permanent  disease  or  derange- 
ment of  the  brain  producing  disordered  action  of  the  mind 
in  such  a  way  as  to  put  the  subject  in  a  condition  varying 
from  his  normal  self  and  out  of  relation  with  his  environ- 
ment" and  we  may  add  generally  "in  such  a  way  as 
to  render  him  dangerous  or  inconvenient  to  himself  or 
others."  Understanding  by  the  words  "dangerous  or 
inconvenient"  all  the  moral  and  legal  disabilities  of 
the  insane,  of  every  kind  and  degree,  this  definition 
fairly  fills  the  requirements  of  the  law,  and  will  not 


l6  INSANITY. 

often  be  disputed.  In  a  medical  point  of  view  it  is 
vague  and  incomplete,  but,  as  stated,  a  satisfactory 
medical  definition  of  insanity  is  an  impossibility. 

The  increase  of  insanity  is  one  of  the  living  questions 
in  modern  civilization.  The  statistics  of  countries 
where  a  reliable  system  of  registration  exists  show 
this  increase.  In  Great  Britain  the  figures  of  the 
English  commissioners  in  lunacy  show  that  in  i860 
one  in  every  523  of  the  population  was  insane;  in 
1870,  one  to  411 ;  in  1880,  one  to  360;  and  in  1890  the 
ratio  had  risen  to  one  in  320.  In  thirty  years  insanity 
had  therefore  increased  from  one  in  523  to  one  in  320, 
or  had  come  unpleasantly  near  to  doubling  the  ratio  to 
population  in  that  period.  The  figures  may  be  ac- 
cepted as  accurate,  and  a  similar  increase  has  been 
noted  in  nearly  every  civilized  country  where  registra- 
tion of  the  insane  exists.  In  our  own  country  we 
cannot  go  back  so  far  with  perfect  confidence  in  our 
figures,  but  the  general  facts  are  very  nearly  the  same, 
allowing  for  the  difference  of  conditions.  The  ratio  of 
insane  to  the  general  population,  according  to  the 
latest  figures,  in  the  State  of  New  York  is  one  to  340, 
and  in  the  State  of  Illinois  it  is  about  one  in  400; 
rather  less  than  the  figures  given  for  Great  Britain. 
The  older  the  country,  within  certain  limits,  the  greater 
the  proportion  of  insanity  as  a  general  rule.  This  is 
notable  in  the  comparative  figures  of  New  York  and 
Illinois;  and  if  we  take  some  other  Western  States 
with  a  less  proportion  of  their  population  living  in 
great  cities  than  is  the  case  in  New  York  or  Illinois, 
the  difference  would  be  still  more  striking.  Insanity 
is  a  disorder  that  thrives  in  urban  populations;  great 
cities  are  hotbeds  of  degeneracy,  and  this  is  one  of 
the  forms  in  which  it  manifests  itself  most  prominently. 

It  is  possible  that  there  is  a  certain  fallacy  in  these 
figures  of  the  increase  of  insanity,  but  not  enough  to 
vitiate  them  to   any  great   extent.     The  better  and 


definition;  prevalence.  17 

more  reliable  the  statistics,  the  less  liable  are  they  to 
underestimate  the  proportion,  and  it  is  highly  probable 
that  their  accuracy  has  been  increasing  with  each 
decade.  Any  probable  error,  in  any  case,  would  be  in 
favor  of  a  better  proportion,  and  of  fewer  insane.  An- 
other point  to  be  considered  is  that  with  modern 
philanthropic  methods  and  appliances  the  death-rate 
of  the  insane  decreases,  and  the  actual  number  alive 
and  under  care  is  increased.  The  proper  method  of 
estimating  the  actual  increase  would  be  not  to  take 
the  actual  proportion,  but  the  number  of  new  cases 
occurring  each  year,  and  this  would  probably  give  us 
somewhat  better  figures.  There  is  little  question, 
however,  of  the  actuality  of  a  certain  steady  increase 
up  to  a  point  where  the  equilibrium  between  cause 
and  effect  is  established,  and  this  is  the  more  difficult 
under  the  conditions  of  change  and  stress  of  modern 
life. 

Still  another  consideration  is  due  in  any  American 
estimate  of  the  increase  of  lunacy:  it  is  that  of  the 
disturbing  factor  of  immigration.  This  alone  is 
enough  to  disturb  the  natural  equilibrium  to  such  a 
degree  as  to  make  statistics  hardly  an  exponent  of  the 
real  condition  of  things.  In  some  parts  of  our  country 
half  or  more  of  the  insane  under  public  care  are  foreign 
born,  and  while  this  is  the  case  it  cannot  be  said  that 
the  conditions  are  equivalent  or  parallel  to  those  ex- 
isting in  an  old  and  long-settled  community,  like  some 
of  the  European  nations,  whose  figures  are  available 
and  are  often  utilized  for  comparison.  The  problem 
is  a  complex  one,  and  the  most  we  can  say  is  that  there 
is  no  question  but  that  insanity  is  increasing  to  some 
extent  in  civilized  nations,  and  those  coming  under 
the  influence  of  civilization.  The  reasons  for  this  fact 
and  the  exact  ratio  of  increase  are  as  yet  unsettled 
questions. 


CHAPTER  II. 
ETIOLOGY. 

In  considering  the  etiology  of  insanity  one  fact  is 
predominant,  that  in  the  vast  majority  of  cases,  what- 
ever be  its  immediate  exciting  cause,  it  is  more  re- 
motely the  result  of  a  predisposition  or  favoring  weak- 
ness, without  which  the  direct  and  obvious  cause  would 
have  been  ineffective.  This  predisposition  is  found 
when  sought  in  nearly  every  case,  and  when  not  found 
may  often  be  inferred  from  the  inadequacy  of  the 
apparent  factors  in  the  causation  of  the  mental  dis- 
order. As  Spitzka  remarks,  the  sane  are  equally 
liable  to  the  exciting  causes  of  insanity,  which  are 
ineffective  in  them ;  it  is  only  those  that  are  especially 
vulnerable  that  suffer  from  such  influences. 

Heredity. — First  among  all  predisposing  factors  of 
insanity  must  be  reckoned  heredity,  or  the  hereditary 
transmission  of  a  liability  to  mental  breakdown  or 
failure.  It  has  been  said  in  courts  of  law  by  prominent 
alienists  that  there  is  no  such  thing  as  hereditary  in- 
sanity, but  such  an  assertion  is  far  less  justifiable  in 
this  case  than  in  that  of  many  other  disorders.  In- 
sanity as  a  result  of  imperfections  of  brain  structures 
that  are  transmissible  may  be  directly  hereditary.  It 
may  appear  at  the  same  period  of  life  in  parent  and 
child,  and  may  even,  as  in  the  case  of  suicidal  impulses, 
be  photographically  similar  in  type  as  well  as  chrono- 
logically equivalent.  In  certain  extreme  forms,  such 
as  idiocy  and  imbecility  and  original  paranoia,  the 
derangement  is  congenital,  and  it  is  in  these  especially 
that  heredity  is  often  the  most  manifest. 

The  part   played  by  heredity  has  been   somewhat 

18 


HEREDITY.  19 

differently  estimated  by  different  authorities,  largely 
on  account  of  special  views  held  as  to  what  heredity 
is,  and  in  part  also  owing  to  the  use  and  dependence 
upon  imperfect  statistics.  A  family  history  of  insanity 
is  often  concealed,  and  in  the  poorer  classes,  who 
largely  fill  the  asylums  from  which  the  statistics  are 
obtained,  there  is  a  very  general  lack  of  data  in  this 
regard.  This  fact  is  noted  by  some  of  the  earlier 
writers,  notably  by  Esquirol,  and  alienists  generally 
recognize  this  possibility  of  error,  though  they  may 
differ  in  their  estimate  of  its  importance.  Confining 
the  heredity  to  that  of  mental  disorder,  however,  some 
of  the  latest  statistics  *  give  a  percentage  of  from  30 
to  35  in  which  there  is  a  family  record  of  direct  or 
collateral  heredity  of  insanity,  which  figure  is  un- 
doubtedly rather  under  than  above  the  truth.  We 
can  probably  say  that  nearly  40%,  at  least,  of  the 
insane  have  some  family  history  of  mental  disease, 
could  all  the  facts  be  known.  If  recent  theories  of 
heredity  are  accepted, — that  of  Galton,  for  example, — 
ancestral  defects  may  be  manifested  even  in  the  fourth 
generation,  and  there  are  comparatively  few  who  are 
able  to  trace  their  family  record  back  to  their  great 
grandparents,  as  regards  mental  health  or  disease; 
there  are  few,  therefore,  who  can  give  a  clean  bill  of 
health  in  this  regard.  If  the  range  of  inquiry  is  ex- 
tended to  cover  eccentricity  or  neurotic  manifestations 
of  one  kind  or  the  other,  the  probabilities  of  finding 
defects  are  vastly  increased. 

There  is,  however,  as  is  well  known,  no  fatal  cer- 
tainty of  the  transmission  of  mental  or  other  defect; 
the  children  of  insane  parents  may  escape  altogether, 
or  it  may  appear  in  only  one  or  two  members  of  a 
family,  or  may  skip  one  or  two  generations.  Insanity, 
however,  is  as  little  liable  to  these  examples  as  other 
disorders,  and,  in  fact,  it  may  be  considered  as  one 

* W.  C.  Krauss:    "Medicine,"  Nov.,  1897. 


20  ETIOLOGY. 

of  the  most  hereditary  of  diseases,  bearing  in  mind, 
at  the  same  time,  that  the  insanity  of  the  parent  is 
no  insurance  of  that  of  the  child,  and  that  if  it  has 
occurred  after  the  birth  of  the  latter,  there  is  a  better 
chance  of  its  escape.  In  that  case  the  offspring  inherits 
only  the  general  weakness  that  caused  the  breakdown 
of  the  parent,  not  the  added  injury  to  the  brain  from 
the  parental  insanity  itself. 

Of  the  two  parents,  the  mother  is,  according  to  the 
almost  universal  authority  of  alienists,  the  one  whose 
insanity  is  most  liable  to  be  transmitted  to  the  child. 
According  to  some  authors,  this  maternal  transmission 
is  twice  as  frequent  as  that  from  the  father,  and  the 
severer  types  of  insanity  are  more  likely  to  be  thus 
inherited.  Dagonet*  suggests  that  as  the  mental  de- 
velopment of  the  female  predisposes  her  more  to  the 
essential  or  simple  types  of  mental  alienation  than 
does  that  of  the  male,  this  fact  may  serve  to  account 
for  the  predominance  of  female  heredity. 

If  besides  the  heredity  of  mental  disease  itself  we 
take  account  of  other  neurotic  and  degenerative  con- 
ditions, we  greatly  enlarge  the  scope  of  hereditary 
influence  in  the  causation  of  insanity.  Eccentricity, 
epilepsy,  hysteria,  "nervousness,"  intemperance,  vaga- 
bondage, and  criminality,  as  well  as  various  organic 
and  functional  (so-called)  neurotic  disorders,  are  very 
often  met  with  in  the  family  histories  of  the  insane, 
and  there  are  certain  disorders,  the  liability  to  which 
is  inherited,  that  may  alternate  in  the  generations 
with  mental  disorder;  among  these  may  be  named 
tuberculosis,  and  especially  gout,  and  what  the  French 
call  the  arthritic  diathesis,  which  is  often  a  manifes- 
tation of  a  liability  to  neuroses  of  various  kinds, 
insanity  being  included  amongst  their  number.  These 
conditions  do  not  necessarily  imply  their  being  followed 
by  insanity,  for  the  reverse  is  generally  the  case,  but 
*  "Maladies  Mentales,"  Paris,  1894.     p.  120. 


HEREDITY.  21 

they  are  sufficiently  often  its  antecedent  as  to  show  a 
probable  connection  between  them. 

Alcoholism  of  parents  is,  on  the  other  hand,  so 
common  an  element  in  the  family  history  of  the  men- 
tally defective  or  deranged  as  to  be  justly  counted  as 
a  predisposing  cause,  and  one  of  the  most  important. 
It  is  especially  manifest  in  the  causes  of  idiocy,  im- 
becility, and  epileptic  insanity,  a  very  large  proportion 
of  the  victims  of  these  afflictions  having  a  history  of 
parental  intemperance.  The  habit  of  drinking  is,  in  a 
sense  of  the  term,  itself  inheritable;  the  children  of 
drunkards  are  often  themselves  more  liable  to  become 
drunkards.  These  are  matters  of  common  popular 
belief,  but  they  have  also  the  authority  of  the  experi- 
ence of  alienists  and  the  medical  profession.  If  in- 
temperance were  as  common  in  the  female  as  in  the 
male  sex,  it  would,  as  a  cause  of  insanity,  be  much  more 
important  than  it  is  at  present. 

Bourn eville  *  found  amongst  iooo  idiots  admitted 
to  the  Bicetre  in  the  decennium  1880  to  1890,  alcoholism 
on  the  paternal  side  in  471 ;  on  the  maternal  side  in  84 ; 
and  on  both  paternal  and  maternal  sides  in  65.  It 
was  denied  in  209,  and  facts  were  not  obtained  in  171. 
In  57  cases  it  was  learned  that  conception  occurred 
during  paternal  intoxication,  and  this  was  probably 
the  case  in  24  more. 

Hysteria,  epilepsy,  and  other  neuroses  in  the  parent 
have  been  already  mentioned.  It  is  not  infrequently 
observed  that  the  parents  of  the  insane  on  one  side 
or  the  other  are  themselves  on  the  borderland  of  in- 
sanity ;  while  not  exactly  over  the  boundary-line,  they 
are  erratic,  peculiar,  "nervous,"  or  otherwise  manifest 
a  degenerative  neurotic  tendency.  We  have  in  these 
cases  what  has  been  called  the  insane  diathesis;  a 
condition  that  tends  to  insanity,  if  not  in  the  individual 
himself,  at  least  in  his  descendants.     This  is  so  common 

*  "  Le  Progres  Med.,"  1897.      21. 


22  ETIOLOGY. 

that  it  is  a  matter  of  popular  faith  that  a  cranky 
parent  is  liable  to  be  a  progenitor  of  insane  offspring. 

Syphilis  in  the  parent  needs  to  be  mentioned  here  in 
connection  with  the  occurrence  of  juvenile  general 
paralysis,  a  disorder  which  is  being  more  and  more 
frequently  reported.  It  is  probable,  however,  that  a 
syphilitic  taint  inherited  from  the  parent  may  be  also 
the  cause  of  other  forms  of  mental  defectiveness, 
idiocy,  epilepsy,  etc. 

Consanguinity  of  parents,  as  a  source  of  intensified 
heredity,  is  a  commonly  accepted  cause  of  insanity,  but 
more  especially  of  idiocy,  deaf-mutism,  etc.  It  is 
worthy  of  mention  here  that  there  appears  to  be  some- 
times a  tendency  of  neurotics  and  defectives  to  inter- 
marry, and  thus  produce  this  concentration  of  morbid 
heredity.  This  has  not  been  very  extensively  noticed 
in  the  literature,  but  some  striking  instances  of  it  have 
been  observed  and  recorded. 

There  are  no  constant  signs  of  a  transmitted  insanity,, 
but  the  victims  of  this  misfortune  often  exhibit  char- 
acteristics that  in  a  general  way  accord  with  their 
unfortunate  inheritance.  They  are  recognized  often 
as  peculiar,  passionate,  unbalanced,  sometimes  bril- 
liant in  some  particular  directions,  from  childhood, 
and  long  before  actual  mental  disease  appears.  In 
other  cases  they  present  no  special  peculiarities,  and 
only  the  family  history  seems  to  show  the  inherited 
predisposition.  All  types  of  insanity  may  be  thus 
consecutive  to  this  bad  heredity,  but  the  degenerative 
types  in  particular,  paranoia,  circular  or  periodic 
insanity,  etc.,  are  most  characteristic  as  regards  the 
prognosis  of  the  attack  itself.  It  is  not  necessarily 
bad  in  the  so-called  curable  forms,  but  relapses  are 
more  apt  to  recur,  and  indeed  are  to  be  expected.  As 
regards  the  especially  degenerative  types,  original 
paranoia,  circular  insanity  of  short  c}rcle,  etc.,  the 
prognosis  is  decidedly  bad. 


HEREDITY.  23 

As  illustrating  the  heredity  of  insanity  with  types 
of  morbid  antecedents,  the  following  analysis  of  a 
study  by  Koller  *  of  the  asylum  statistics  at  Zurich 
is  of  service:  In  a  total  of  1850  patients,  78.2%  were 
found  hereditarily  predisposed,  and  this  heredity  was 
slightly  greater  (6.8%)  in  the  females  than  in  the 
males.  The  greatest  percentage  of  hereditary  pre- 
disposition, as  might  have  been  expected,  was  found 
in  the  congenital  types  of  derangement,  and  the  least 
in  epileptic  insanity,  which  is  to  a  certain  extent  due 
to  accidental  traumatisms.  The  percentages  of  hered- 
ity for  the  chief  divisions  of  mental  alienations  are 
given  as  follows: 

Congenital  insanities 86.3 

Epileptic  insanities 65.2 

Paralysis,  senile  and  organic 70.9 

Simple  idiopathic  psychoses   81.9 

Alcoholic  insanity  (females) 79.2 

(males)   69. 1 

As  regards  the  types  of  parental  disorder  that  are 
most  liable  to  become  transmitted  as  insanity  in  the 
children,  Dr.  Koller  reckons  the  simple  idiopathic 
psychoses  in  the  first  rank  (49%),  intemperance  of 
parents  next  (20%),  psychopathies  (19%)  and  other 
conditions,  such  as  apoplexy,  nervous  disorders, 
organic  and  senile  insanities,  etc.,  in  a  slighter  per- 
centage. Idiopathic  insanity  in  the  mother  was  found 
to  be  much  more  perilous  to  the  offspring  than  that 
of  the  father;  thus,  with  maternal  insanity  of  this  type 
the  percentage  of  mental  disorder  was  in  sons,  48.9; 
in  daughters,  48.6.  With  paternal  insanity,  on  the 
other  hand,  the  percentage  was  for  the  sons,  23.5 ;  for 
the  daughters,  28.3.  Psychopathies  in  the  mother 
were  also  more  influential  in  transmission,  but  the  case 
was  reversed  in  case  of  parental  intemperance,  that 
of  the  father  transmitting  mental  disorder  to  the  sons 

*"Archivf.  Psychiatrie,"  1895.      268-294. 


24  ETIOLOGY. 

in  the  percentage  of  44.7,  and  to  the  daughters  of  33.9, 
while  maternal  intemperance  gave  a  percentage  of 
only  1 0.0  for  the  sons  and  5.7  for  the  daughters. 

These  findings  are  not  by  themselves  so  conclusive 
as  would  be  those  from  more  extensive  statistics,  but 
they  agree  in  the  main  with  experience  and  observa- 
tions elsewhere,  and  illustrate  the  general  laws  govern- 
ing the  hereditary  transmissions  of  insanity,  or,  if  it 
be  considered  better,  hereditary  predisposition  to 
insanity 

Other  Predisposing  Causes .  —  Civilization.  —  After 
hereditary  defect,  the  conditions  of  modern  life  are 
perhaps  more  largely  responsible  than  any  other 
factors  for  the  increase  and  extension  of  insanity. 
While  lunatics  are  not  unknown  amongst  primitive 
peoples,  and  are  probably  more  frequent  than  appear- 
ances would  indicate,  inasmuch  as  there  is  little  care 
given  to  their  survival,  and  therefore  any  accumula- 
tion of  insanity  is  improbable  among  them,  it  is  in 
civilized  countries  that  the  frequency  of  insanity  is 
incomparably  the  greatest.  It  is  especially  in  those 
countries  where  civilization  has  made  the  greatest 
advances  and  life  is  more  intense  that  we  find  mental 
aberration  most  frequent.  In  urban  communities, 
also,  rather  than  in  the  country,  this  tendency  is  seen 
most  plainly ;  it  is  our  great  cities  that  fill  our  asylums 
and  that  furnish  the  majority  of  suicides  and  other 
evidences  of  unbalanced  and  disordered  mind.  This 
is  in  part  due  to  the  effects  of  stress,  and  the  competi- 
tion of  modern  life,  upon  minds  that  under  other  con- 
ditions might  have  remained  sound,  and  in  part  to  the 
tendency  of  these  human  agglomerations  to  produce 
degenerates  and  defectives.  Men  live  in  crowded 
cities  under  unnatural  conditions,  and  perfect  mental 
or  moral  development  cannot  be  the  rule  so  much  as 
in  the  healthier  surroundings  of  village  or  country  life. 
In  these  latter,  too,  the  average  mediocre  intellect  can 


OTHER    PREDISPOSING    CAUSES.  25 

find  its  medium,  in  which  it  can  safely  thrive,  while  it 
would  be  much  more  likely  to  succumb  if  transplanted 
into  the  hurry  and  bustle  and  the  fierce  struggle  for 
existence  of  city  life.  Even  savages  suffer  mentally 
by  contact  with  a  higher  civilization  and  in  the  presence 
of  conditions  that  tax  and  confuse  their  intellects,  and 
they  succumb  to  civilized  vices  without  taking  advan- 
tage of  the  better  gifts  of  civilization.  In  the  same 
way  the  foreigners,  who  are  so  numerous  in  our  asylums, 
are  largely  the  result  of  the  change  from  a  quiet  peasant 
life  to  new  and  more  trying  conditions.  The  blacks  in 
the  Southern  States,  when  in  slavery,  furnished  fewer 
cases  of  mental  disorder  than  since  they  have  had  to 
assume  the  responsibilities  of  freedom.  Modern  civil- 
ization in  its  intense  form  may  be  said  to  render  every 
mind  below  a  certain  grade  that  is  brought  fully  under 
its  influence  more  or  less  predisposed  to  insanity. 

It  is  a  fact  we  have  observed,  and  we  believe  that 
statistics  will  bear  us  out,  that  in  the  more  highly  civil- 
ized communities  the  depressive  types  are  more  frequent, 
and  that  their  proportion  to  the  whole  number  is  increas- 
ing. Just  what  other  causes  are  active  in  producing  this 
is  not  certain,  but  we  believe  that  civilization  is  one 
factor.  This  change  of  type  has  been  specially  noticed 
of  late  years  in  certain  special  types  of  mental  de- 
rangement, but  it  exists  also  in  other  insanities  to 
a  certain  extent. 

A  good  instance  of  this  tendency  is  found  in  paresis, 
a  disease  generally  remotely  due  to  an  acquired  con- 
stitutional vice  that  has,  in  all  probability,  existed  in 
past  centuries  even  more  extensively  than  at  present . 
Under  the  added  conditions  of  worry,  stress,  etc.,  of 
modern  life,  this  has  of  late  years  made  paresis  the 
special  disease  of  the  nineteenth  century. 

Modern  educational  methods,  so  far  as  they  are 
responsible  for  mental  breakdown,  are  so  as  they  are 
a  feature  of  modern  civilization.     The  effects  in  this 


26  ETIOLOGY. 

way  of  vicious  education,  lack  of  proper  training,  etc., 
fall  rather  under  the  head  of  direct  exciting  causes. 

We  do  not  find  in  our  experience  the  statement 
entirely  correct  that  brain-workers  are  specially  subject 
to  mental  breakdown,  although  there  is  sometimes  an 
appearance  of  this.  It  may  be  different  in  some  other 
countries,  Scotland,  for  example ;  *  but  in  this  country 
the  great  mass  of  insanity  is  recruited  from  the  ignorant 
or  imperfectly  educated,  and  those  of  higher  or  more 
thorough  education  are  hardly  represented  in  due  pro- 
portion, at  least  in  our  public  asylums  in  some  portions 
of  the  country. 

Age. — As  a  predisposing  cause  of  insanity,  age  has 
an  important  part,  as  certain  types  are  directly  con- 
nected with  the  different  stages  of  life.  Insanity,  apart 
from  idiocy  or  imbecility,  is  rare  in  childhood,  becomes 
more  common  at  puberty,  is  most  frequent  in  early 
manhood,  and  slightly  declines  in  frequency  as  age 
advances,  though  this  is  partly  due  to  the  lesser  ex- 
pectancy of  life  at  these  ages.  The  victims  of  insanity 
die  much  more  rapidly  than  the  sane,  hence  the  smaller 
percentage  of  lunatics  past  middle  life.  It  is  true, 
however,  that  the  onset  of  insanity  is  slightly  less 
frequent  between  forty  and  sixty  than  between  thirty 
and  forty,  so  that  the  smaller  percentage  of  lunatics 
between  these  ages  may  be  partly  thus  accounted  for. 
Dagonet  gives  the  following  as  the  averages  for  each 
period  of  life,  after  puberty: 

From  15  to  20 7  in  100  insane,  or  1  to  14 


"       20  to  30 21   ' 

"       30  to  40 29   ' 

"       40  to  50 24  ' 

"       50  to  60 11   ' 

After  60 7   ' 


1  to  5 
1  to  3 
1  to  4 
1  to  9 
1  to  14 


These  figures  of  Dagonet  seem  high  for  the  earlier 
period    of   life, — from    fifteen   to   twenty, — but   they 

*McPherson:   "Mental  Affections,"  p.  40. 


OTHER    PREDISPOSING    CAUSES.  27 

probably  fairly  represent  the  facts  for  the  other  ages. 
By  far  the  largest  proportion  of  cases  occurs  between 
the  ages  of  twenty  and  fifty,  and  each  extreme  of  this 
period  approximates  a  critical  vital  period,  the  close 
of  adolescence  and  the  change  of  life. 

The  infrequency  of  insanity  here  in  old  age  is  only 
apparent ;  the  senile  changes  in  the  brain  are  especially 
favorable  to  certain  forms  of  mental  failure,  which, 
however,  are  not  always  accounted  as  actual  insanity. 
It  is  at  this  period  also  that  relapses  occur  of  former 
mental  diseases,  and  it  is  generally  held  that  the 
climacteric  period  in  women  is  an  especially  critical  one 
in  this  respect.  On  the  other  hand,  it  is  occasionally 
observed  that  old  cases  of  long  duration  make  a  re- 
covery or  pronounced  betterment  at  this  period. 
Puberty  is  also  another  critical  period  that  gives 
its  particular  type  to  the  mental  disorder. 

Sex. — The  relation  of  the  climacteric  in  women  to 
insanity  has  just  been  mentioned.  Sex  has,  in  other 
respects,  also,  an  influence  in  the  causation  of  the 
disorder.  Certain  causes,  such  as  child-birth,  lacta- 
tion, pregnancy,  are  peculiar  to  the  female  sex;  others, 
like  alcoholism,  traumatisms,  etc.,  affect  more  par- 
ticularly the  male  sex.  Aside  from  insanity  due  to 
alcoholism  and  the  ever-increasing  paresis,  there  are 
probably  more  insane  women  than  men,  the  difference 
being  due  largely  to  the  more  fatal  character  of  the 
disorder  in  the  male  sex. 

Civil  Condition. — It  is  a  generally  recognized  fact 
that  marriage  is  conducive  to  sanity  as  compared  to 
celibacy.  The  causes  of  this  are  doubtless  to  be  sought 
for  in  the  more  natural  and  healthful  life  of  the  married 
than  in  the  unmarried,  the  lesser  temptations  to  im- 
morality, and,  in  females  at  least,  the  natural  fulfil- 
ment of  their  physiologic  destiny.  In  the  widowed 
insanity  is  somewhat  more  frequent  than  in  the  married 
state,  but  far  less  so  than  in  celibates.     According  to 


28  ETIOLOGY. 

French  statistics  (Dagonet),  the  relative  liability  is  in 
celibates  nearly  three  times  and  in  the  widowed  nearly 
twice  as  great  as  in  the  married. 

Professions  and  Occupations. — But  little  need  be 
said  on  this  point.  It  is  easy  to  see  how  certain  occu- 
pations favor  the  occurrence  of  insanity  more  than 
others.  Such  are  those  which  involve  exposure  to 
toxic  agents,  or  special  temptations  to  vicious  habits, 
those  that  require  irregular  or  unnatural  habits  of  life, 
like  those  of  sailors,  soldiers,  railroad  employees,  com- 
mercial travelers,  liquor  dealers,  and,  to  a  certain 
extent,  those  engaged  in  speculative  pursuits,  where 
there  is  always  a  degree  of  mental  strain  and  abrupt 
changes.  Prisoners,  aside  from  the  fact  that  they  are 
already  largely  degenerates,  are  liable,  from  the  con- 
finement and  monotony  of  their  condition,  to  become 
subjects  of  mental  disorder.  In  short,  any  occupation 
that  is  physically  unhealthful  or  exposes  to  special 
temptations  may  be  considered  as  conducive  or  predis- 
posing to  mental  disease. 

Climate,  Race,  Political  Conditions,  etc. — Climate  can 
hardly  be  considered  as  affecting  the  chances  of  the 
occurrence  of  mental  disorder,  though  it  is  possible  it 
may  have  its  effect  upon  the  other  factors,  the  time  of 
its  appearance  and  its  type.  The  relations  of  race  to 
insanity  have  been  studied  by  some  authors,  and  there 
is  a  general  agreement  in  their  findings,  but  the  data 
are  incomplete  and  imperfect.  The  Jews  appear  to 
be  especially  liable  to  insanity,  though  they  are  ap- 
parently less  liable  to  certain  forms,  like  general  paresis. 
The  northern  races,  the  Scandinavians  and  Germans, 
according  to  the  statistics,  seem  more  liable  than  the 
southern  ones  to  the  depressive  types  of  insanity,  and 
this  is  apparently  true  to  some  extent  in  the  northern 
sections  of  the  same  race.  The  northern  Slavs,  in 
Russia,  give  a  predominance  of  melancholic  type, 
while  the  southern  Slavs,  in  Austria,  are  more  generally 


MORAL    CAUSES.  20- 

of  the  excited  type.  Whether  this  is  a  matter  of  race 
or  climate,  or  of  other  conditions,  political  or  otherwise, 
it  is  impossible  to  say  with  our  present  knowledge,  and, 
as  stated,  the  data  are  too  imperfect  for  positive 
generalizations. 

EXCITING  CAUSES  OF  INSANITY. 

From  what  has  been  said  it  will  be  understood  that 
with  an  existing  predisposition  admitted,  almost  any- 
thing that  could  sufficiently  disturb  the  normal  healthy 
action  of  the  brain  may  give  rise  to  more  or  less  lasting 
mental  derangement.  The  exciting  causes  of  insanity 
are,  therefore,  infinitely  numerous,  and  it  is  possible 
to  enumerate  only  those  that  are  most  frequent  and 
permanent  among  them. 

Moral  Causes. — The  so-called  moral  or  emotional 
causes  of  insanity  are,  for  the  most  part,  only  evidences 
of  a  strong  predisposition,  or  pronounced  mental  in- 
stability, that  requires  only  the  slightest  touch  to 
disturb  its  balance.  In  a  certain  proportion  of  cases, 
however,  they  represent  actually  efficient  factors 
sufficient  to  break  down  even  a  normal  mental  con- 
stitution. Taken  altogether,  they  account,  at  least 
ostensibly,  for  nearly  or  quite  one-half  of  all  cases  of 
mental  disorder. 

Mental  Shock. — It  happens  occasionally  that  the 
apparent  beginning  of  an  attack  of  insanity  dates  from 
a  mental  shock,  fright,  the  hearing  of  bad  news,  the 
death  of  a  dear  friend,  or  some  other  strong  or  sudden 
cause  of  emotional  excitement  or  disturbance.  The 
psychic  effects  of  such  are  so  well  known  that  it  is 
needless  to  dilate  upon  them,  and  it  is  therefore  the 
more  easy  to  conceive  how  they  can  produce  mental 
derangement.  It  is  possible  that  this  cause  is,  as  some 
have  suggested,  more  common  than  is  generally 
supposed. 

Domestic    Troubles. — Among  the   alleged   causes   of 


30  ETIOLOGY. 

insanity  in  reports  of  hospitals  and  asylums,  domestic 
troubles  have  a  rather  prominent  position.  In  the 
reports  of  two  New  York  asylums  (Utica  and  Bing- 
hampton)  for  the  nine  years  ending  in  1896,  this  cause 
was  alleged  as  responsible  for  the  insanity  of  377 
out  of  a  total  of  6842,  or  5.4%.  If  we  add  financial 
worry  and  trouble  to  this,  the  proportion  is  decidedly 
greater.  It  is  these  that  are  in  all  probability  the 
direct  exciting  causes  of  paresis  in  a  large  proportion, 
at  least,  of  all  the  cases.  Their  importance  is  therefore 
an  increasing  one. 

Disappointments  in  Love. — These  are  also  popularly 
considered  as  frequent  causes  of  insanity,  but  are 
probably  seriously  effective  only  in  strongly  predis- 
posed individuals.  They  furnish  at  best  only  a  very 
small  percentage  of  the  cases  of  insanity  from  moral 
causes. 

Religious  Excitement. — This  is  another  probably  over- 
rated cause  of  insanity.  It  does  not  follow  because 
insanity  has  a  religious  tinge  that  it  originated  from 
religious  emotional  disturbances;  the  exact  reverse  of 
this  is  sometimes  the  case.  It  occurs,  however,  some- 
times that  in  revivals  or  on  other  occasions  predisposed 
and  neurotic  individuals  occasionally  break  down 
mentally,  either  temporarily,  or,  it  may  be,  occasionally 
into  lasting  insanity.  In  religions  that  demand  exces- 
sive bodily  austerities,  in  the  way  of  fastings,  penances, 
etc.,  it  is  not  improbable  that  they  may  often  be  the 
cause  of  mental  disease. 

The  other  possible  moral  causes  of  mental  disorder 
hardly  require  notice.  Anything  that  can  intensely 
excite  the  emotions  may  under  certain  circumstances 
cause  mental  breakdown.  It  is  possible  that  some  of 
the  cases  of  post-connubial  insanities  reported  may 
have  been  thus  caused  by  the  shock  to  virgin  modesty, 
or  the  realization  of  virile  incapacity,  at  least  in  part. 

Physical  Exciting  Causes. — These  include  the  great 


PHYSICAL    EXCITING    CAUSES.  31 

mass  of  etiologic  factors  of  insanity,  and  cover  the 
widest  possible  range ;  a  large  proportion  of  them  may 
be  roughly  classified  into  traumatic,  toxic,  exhaustive, 
and  organic  causes.  Of  these,  the  first-named  class 
is  the  least  frequent  and  important;  the  other  three 
often  cooperate  in  the  same  case  or  individual.  To 
these  should  be  added  developmental  factors  which 
have  an  important  part  in  the  production  of  certain 
forms  of  insanity,  sometimes  even  independently  of 
the  three  previously  named. 

Developmental  and  Critical  Periods. — There  are  sev- 
eral important  periods  in  human  life  that  have  a  more 
or  less  pronounced  influence  upon  mental  development 
and  health,  and  that  may  so  affect  it  as  to  produce 
idiocy,  imbecility,  or  insanity.  The  first  of  these, 
when  acquired,  originates  in  the  earliest  critical  period, 
that  of  infancy.  The  early  exposures,  the  infectious 
diseases  affecting  development,  and  traumatisms,  all 
have  their  part  in  these  changes.  In  the  second  im- 
portant developmental  period,  that  of  puberty  and 
adolescence,  we  have  the  beginning  of  certain  degenera- 
tive or  quasi-degenerative  forms  of  insanity,  to  which 
the  victims  sometimes  seem  to  have  been  predestined 
from  birth,  or,  as  the  heredity  in  these  cases  is  generally 
manifest,  from  generations  before.  At  the  close  of  the 
reproductive  period  of  life,  especially  in  females,  there 
is  another  change,  the  importance  of  which  as  a  cause 
of  mental  disorder,  though  probably  overrated,  is  yet 
a  considerable  one.  The  insanity  of  old  age  has  been 
already  mentioned,  but  so  far  as  it  is  due  to  the  natural 
changes  of  age,  it  also  falls  to  some  extent  under  this 
head,  which  includes  not  only  the  incidents  of  the 
evolution  of  the  individual,  but  also  those  of  his  gradual 
dissolution  or  decay. 

Traumatic  Causes.— Under  this  head  are  included 
not  only  traumatisms  that  can  directly  or  indirectly 
affect  the  central  nervous  system,  but  also  insolation, 


32  ETIOLOGY. 

physical  or  surgical  shock,  and  whatever  else  may  in 
the  way  of  accidental  or  purposed  injury  disturb  the 
intellectual  or  emotional  life  in  such  a  way  and  to  such 
a  degree  as  to  cause  what  we  may  call  insanity.  Trau- 
matisms themselves,  apart  from  those  of  the  brain,  are 
probably  less  liable  to  give  rise  to  actual  insanity  than 
to  neurasthenic  or  hysteric  symptoms,  such  as  are 
not  infrequently  observed  from  railway  injuries  and 
similar  accidents.  Sunstroke,  in  this  country,  is  a 
well-known  cause  of  mental  disorder,  which  may  pos- 
sibly be  manifested,  however,  at  a  date  rather  remote 
from  the  accident  itself.  Surgical  operations,  espe- 
cially those  upon  the  genital  organs  and  the  eyes,  have 
been  credited  with  the  origination  of  mental  disorder, 
and  considerable  has  been  written  of  late  years  upon 
this  special  point.  It  seems  not  improbable  from  what 
we  know  of  the  effects  of  castration  in  man  and  animals 
that  there  is  truth  in  this  reference,  but  recent  acquisi- 
tions as  to  the  effects  of  ablation  of  the  internally 
secreting  glands,  to  which  class  the  ovaries  and  tes- 
ticles probably  in  part  belong,  suggest  that  there  may 
be  an  autotoxic  element  also  in  the  insanity  thus 
produced.  The  possible  effect  of  powerful  narcotics, 
such  as  the  anesthesias  employed,  is  a  factor  not  to 
be  neglected  in  this  connection,  and  leads  to  the 
consideration  of  the  next  class. 

The  effects  of  gynecologic  disorders  in  the  production 
of  mental  disease  is  insisted  upon  by  a  school  of  alienists 
in  this  country,  and  especially  in  Canada,  at  the  present 
time,  but  the  general  consensus  of  opinion  amongst 
alienists  and  neurologists  scarcely  agrees  with  them. 
It  is  quite  possible  that  in  some  cases  operative  inter- 
ference for  diseased  conditions  of  the  female  organs  of 
generation  may  have  good  effects,  but  this  does  not 
prove  that  they  were  the  sole  cause  of  the  mental 
disease.  As  a  cooperating  cause  they  may  very  well 
be  of  importance  in  many  cases. 


PHYSICAL    EXCITING    CAUSES.  33 

Toxic  Causes. — As  usually  understood,  these  include 
the  toxic  substances  or  agencies  that  may  give  rise  to 
mental  disorder,  such  as  alcohol,  morphia,  cocain, 
absinthe,  lead,  chloral,  etc.,  and  also  paludal,  syphilitic, 
etc.,  infections.  To  these  may  also  be  properly  added 
the  auto-intoxications  from  the  retention  of  products 
that  should  normally  be  eliminated,  or  their  overpro- 
duction in  the  system.  Of  late  years  the  auto-intoxi- 
cations have  been  more  and  more  invoked  for  numerous 
ailments,  and  insanity  is  one  of  these  that  gives  a  wide 
range  for  this  possible  action.  Many  cases  of  insanity 
that  were  formerly  attributed  to  sympathetic  or  reflex 
influences  are  now  considered  to  be  due  to  an  auto- 
intoxication, it  may  be  from  the  digestive  tract,  or 
possibly  from  the  over-  or  under-functionings  of  some 
one  of  the  important  internal  secretions. 

The  most  notable  perhaps  of  mental  defects  from 
deficient  gland  secretion  is  seen  in  cretinism,  and  the 
mental  symptoms  of  myxedema  are  a  milder  mani- 
festation of  the  same  morbid  state.  Other  forms  of 
mental  disorder  from  special  gland  disease  are  not  so 
clearly  established,  at  least  so  far  as  the  direct  relation 
of  cause  and  effect  is  concerned.  It  is  easy  to  con- 
ceive, however,  of  mental  disorder  from  deficient 
action  of  the  liver  in  excluding  toxins  from  the 
circulation  or  from  impaired  renal  functions,  etc.  In 
these  last  cases  the  question  often  arises,  nevertheless, 
as  to  whether  the  insanity  itself  may  not  directly  or 
indirectly  give  rise  to  the  organic  disease-,  or  whether 
both  may  not  have  a  common  cause.  Imperfectly 
functioning  kidneys  are  almost  a  normal  occurrence 
at  times,  but  the  disordered  action  may  not  extend  to 
a  pronounced  morbidity,  though  it  is  probable  that  an 
absolutely  sound  kidney  in  advanced  or  even  in  adult 
life  is  almost  the  exception  rather  than  the  rule.  In 
insanity  the  chances  of  kidney  derangement  are  in- 
creased in  many  ways,  and  it  is  not  remarkable  that 
3 


34  ETIOLOGY. 

disease  of  these  organs  should  be  very  frequently  met 
with  in  the  insane.  The  direct  etiologic  relation  of 
these  conditions  therefore,  though  often  probable,  is 
not  always  clearly  demonstrable. 

Auto-intoxication  from  the  digestive  tract,  and 
especially  intestinal  auto-intoxication,  is  one  of  the 
best-established  etiologic  factors  of  insanity,  and  its 
practical  importance  will  be  noted  later  on.  Its  im- 
portance is  not  always  as  much  emphasized  in  this 
relation  as  it  should  be.  As  regards  derangements  of 
general  metabolism  in  various  diseased  conditions  much 
might  also  be  said,  as  well  also  in  regard  to  the  effects 
of  bacterial  and  other  organic  toxins  in  the  production 
of  mental  affections.  It  would  probably  be  possible 
to  find  cases  of  insanity  occurring  after  every  form  of 
serious  bodily  disease,  and  we  might  make  an  etiologic 
species  for  each.  In  the  severer  infectious  disorders 
mental  derangement  is  a  comparatively  frequent  se- 
quence, and  is  in  many  cases  and  to  a  large  extent 
due  to  the  toxins  of  the  disease.  There  is  no  reason 
why  special  bacterial  toxins  may  not  have  their  own 
special  effects,  and  in  some  cases  color  the  mental 
disorder  as  do  the  special  neurotic  poisons  that  are  so 
commonly  the  cause  of  temporary  or  lasting  mental 
derangement.  It  has  not  seemed  necessary,  however, 
to  us  to  recognize  all  the  different  etiologic  forms  that 
have  been  proposed,  and  we  do  not  believe  the  clinical 
syndromes  are  so  constant  or  pronounced  as  to  justify 
the  distinctions. 

Drug,  etc.,  Intoxications. — Of  these,  alcohol  certainly 
takes  the  lead  as  a  cause  of  mental  disease.  It  is  itself 
directly  the  cause  of  many  cases  of  insanity  and  in- 
directly is  responsible  for  even  a  much  larger  pro- 
portion. Acute  alcoholism— delirium  tremens — is 
itself  a  sort  of  insanity,  but  this  is  not  usually  reckoned 
when  estimating  the  proportion  of  mental  disorders 
caused  by  alcohol.     The  estimates  vary  from  8  or  10 


PHYSICAL    EXCITING    CAUSES.  35 

to  20  or  even  40%.  Some  years  ago  one  of  us  made  as 
careful  a  study  of  this  subject  of  the  alcoholic  etiology 
of  insanity  as  appeared  possible  at  the  time,  and  came 
to  the  conclusion  from  his  inquiries  and  observations 
that  about  10  or  12%  of  all  cases  could  be  directly 
attributed  to  this  cause;  i.  e.,  that  it  was  the  chief  if 
not  the  sole  agent  in  the  causation  of  that  percentage 
of  cases.  This  agrees  fairly  with  other  estimates  by 
alienists  who  have  studied  the  subject.  Indirectly 
and  as  a  cooperating  cause  its  action  has  a  much  wider 
range,  and  it  may  thus  even  have  its  part  in  as  much 
as  50%  of  all  cases.  Any  estimate,  however,  can  be 
only  an  approximate  one,  but  the  main  fact  remains 
that  it  is  one  of  the  most  important  causes  of  mental 
derangement.  As  a  direct  cause  it  is  effective  chiefly 
in  the  male  sex ;  women  are  much  less  frequently  its 
victims.  Kraepelin,  who  is  a  careful  observer,  finds 
only  about  6%  of  his  alcoholic  cases  in  women  in 
Germany,  where  a  certain  amount  of  alcoholic  indul- 
gence is  more  common  in  females  than  in  this  country. 
It  is  not  likely  that  the  figure  would  be  exceeded  here. 
Indirectly,  however,  they  suffer  as  much  or  more  than 
men  from  this  cause,  and  the  amount  of  insanity  in 
women  due  to  the  poverty,  abuse,  domestic  troubles, 
and  hardships  caused  by  intemperance  is  probably 
greater  than  that  in  men.  As  regards  abuse,  it  is 
often  given  as  a  cause  of  derangement  in  women,  but 
we  have  never  seen  but  once  the  cause  given  as  abuse 
by  a  drunken  wife.  According  to  Clouston,  the  per- 
centage of  insanity  due  to  alcohol  is  increasing,  it 
having  reached  24  in  his  own  institution. 

The  modus  operandi  of  alcohol  in  causing  mental 
disease  is  through  its  direct  action  on  the  nervous 
system,  which  has  been  studied  to  a  certain  extent  by 
Kraepelin  and  others,  but  which  will  be  more  par- 
ticularly noticed  when  we  come  to  describe  alcoholic 
insanity.     Mention    has    already    been    given    to    the 


36  ETIOLOGY. 

effects  of  alcohol  on  heredity  and  the  production  of 
mental  disease  in  the  offspring  of  its  victims. 

Morphin  and  cocain  are  other  powerful  drugs  that 
produce  insanity  of  special  types,  and  are,  like  that 
from  alcohol,  noticed  more  particularly  in  the  special 
portion  of  this  work.  Other  drug  intoxications 
wTorthy  of  mention  are  those  from  lead,  which  may 
produce  paretic  symptoms,  and  which  we  have  ob- 
served as  of  an  obstinately  suicidal  depression,  chloral, 
mercury,  the  toxin  of  pellagra  from  diseased  corn, 
etc. ;  these  are  all  of  interest,  but  their  frequency  in 
this  country  is  slight,  and  they  are  hardly  appreciable 
as  causing  any  proportion  of  the  aggregate  of  insane 
cases. 

Lastly,  we  may  notice  the  toxins  of  certain  diseases, 
and  the  only  one  calling  for  very  special  remark  on 
account  of  its  importance  as  a  cause  is  that  of  syphilis. 
This,  through  its  direct  action  on  the  nerve-centers, 
may  be  an  immediate  exciting  cause,  or  it  may  so 
prepare  the  system  for  the  action  of  other  exciting 
causes  as  to  be  a  very  important  factor  in  the  etiology. 
In  the  first  case  we  have  the  lesions  of  syphilis,  the 
gummata,  the  meningeal  and  vascular  inflammations, 
the  general  cachexia  of  the  disease,  etc.  In  the  latter 
the  action  is  more  mysterious;  it  would  seem  as  if 
there  was  a  toxin  lying  latent  in  the  system,  but  called 
out  into  action  by  some  other  condition  or  cause,  such 
as  worry  or  overwork.  This  parasyphilitic  insanity 
is  chiefly  seen  in  the  form  of  paresis  or  paretic  dementia, 
which  is  now  generally  recognized  as  a  toxic  insanity, 
and  almost,  if  not  quite,  always  with  syphilis  as  an 
antecedent.  It  may  perhaps  be  rightly  considered  as 
a  sort  of  late  syphilitic  manifestation,  a  quaternary 
form  of  the  disease.  We  have  only  recently  come  to 
accept  its  syphilitic  nature,  and  there  is  much  yet  in 
its  etiology  to  be  studied  and  worked  out. 

An  insanity  of  tuberculosis  is  recognized  by  some 


PHYSICAL    EXCITING    CAUSES.  37 

as  a  toxic  insanity,  and  it  is  such  through  the  disorders 
of  the  general  metabolism  it  induces  in  its  later  stages, 
when  the  mental  disease  usually  appears.  The  evi- 
dence that  it  is  directly  due  to  any  bacterial  toxin, 
like  the  virus  of  syphilis,  seems  to  us,  however,  to  be 
lacking. 

Exhaustion. — It  is  difficult  often  to  separate  the 
insanities  of  nervous  exhaustion  from  those  due  to 
toxins,  either  of  internal  or  external  origin.  The 
post-febrile  insanities,  which  are  typical  in  their  phases 
of  nervous  weakness,  may  be  due  to  one  cause  as  much 
as  to  the  other,  and  even  in  those  cases  from  overstrain 
and  stress  acting  directly  upon  the  nerve  elements  it 
is  not  always  possible  to  exclude  a  toxic  factor.  We 
know,  however,  with  tolerable  certainty  that  there  is 
a  nervous  exhaustion  from  fatigue,  and  from  lack  of 
balance  between  waste  and  nutrition,  that  may  go  to 
the  length  of  destroying  mental  equilibrium,  and  often 
does  so,  thus  producing  what  may  be  called  a  pure 
exhaustive  psychosis.  This  may  occur  after  wasting 
diseases,  after  overwork,  physical  or  mental,  after  hard- 
ships and  starvation,  masturbation  and  sexual  excesses, 
and  whatever  depresses  nutrition  and  fatigues  the  nerve- 
cells  without  allowing  proper  restoration  for  sufficient 
periods. 

Organic  Causes. — These  include  gross  diseases  of  the 
brain,  such  as  occur  from  arterial  disease,  sclerotic 
changes,  hemorrhages,  embolism,  etc.  Under  this  head 
we  have  apoplexies,  softenings,  senile  wasting,  neu- 
ritis, morbid  growths,  etc. 

In  conclusion,  it  should  be  said  that  in  perhaps  a 
majority  of  instances  the  attack  of  insanity  has  more 
than  one  of  these  classes  of  causes  in  play  in  its  origina- 
tion. Thus,  in  the  case  of  paresis  which  is  directly 
excited  by  worries  and  mental  stress  there  must  be, 
as  a  rule,  a  system  prepared  by  the  toxins  of  specific 
disease.     In  many  cases,  also,  of  exhaustive  insanity, 


38  ETIOLOGY. 

some  toxic  agency,  mental  shock,  or  some  other  dis- 
turbing factor  enters  into  the  production  of  the  attack. 
The  causes  of  any  attack  of  insanity  are  not  always 
obvious,  and  often  require  close  study;  sometimes  the 
alleged  or  supposed  causes — for  example,  masturbation 
or  religious  excitement — are  found  to  be  mere  early 
symptoms,  and  to  have  no  etiologic  connection  what- 
ever with  the  disease.  On  account  of  these  facts 
hospital  statistics  are  unreliable  to  a  large  extent,  as 
they  give,  as  a  rule,  only  the  alleged  causes  as  stated 
in  the  paper  of  commitment,  which  are  very  often 
erroneous. 

In  every  case  the  remote  as  well  as  the  apparent 
immediate  causes  should  be  taken  into  consideration, 
and  questions  of  hereditary  taint,  neurotic  personal 
antecedents,  previous  habits,  etc.,  be  thoroughly  in- 
vestigated. It  must  be  remembered,  also,  that  in  most 
cases  the  causal  factors  are  multiple ;  it  is  not  the  rule 
for  any  one  to  be  the  sole  agency  in  producing  the 
insanity.  This  is  true  of  the  exciting  causes  by  them- 
selves, and  still  back  of  these  we  have  to  reckon  with 
the  great  predisposing  influences  which  are  in  action 
in  nearly  every  case. 

In  conclusion,  something  should  be  said  of  the  con- 
tagion of  insanity.  It  is  popularly  believed  that  those 
who  have  to  do  with  and  care  for  the  insane  are  them- 
selves specially  liable  to  be  similarly  afflicted.  This 
is  true  only  when  predisposition  exists;  the  contagion 
is  purely  mental,  the  influence  of  association,  and 
generally  implies  a  pre-existing  mental  weakness  on 
the  part  of  the  recipient.  Folie  a  deux,  or  communi- 
cated or  imposed  insanity,  is  the  imposition  by  a 
stronger  mind  on  a  weaker  one  of  its  own  delusions. 
It  is  generally  observed  in  cases  of  very  close  association 
and  relationship,  as  between  parent  and  child,  brothers 
and  sisters;  and  the  communicated  insanity  is  very 
generally  cured  by  removal  from  contact  or  association 


PHYSICAL    EXCITING    CAUSES.  39 

with  the  imposing  agent.  Only  when  both  are  alike 
seized  with  similar  delusions,  and  neither  one  is  the 
passive  party  rather  than  the  other, — the  so-called 
simultaneous  insanity, — is  the  prognosis  alike  unfavor- 
able for  both. 

It  is  not  well,  as  a  rule,  for  children  or  young  persons 
in  the  formative  stage  of  mind  or  character  to  too 
intimately  associate  with  the  insane,  though  the  danger 
is  probably  not  so  great  as  is  popularly  supposed. 
This  is  especially  the  case  when  insanity  is  in  the 
family,  as  then  a  predisposition  may  be  assumed  to 
exist.  This  has  an  important  practical  bearing  on  the 
question  of  the  home  treatment  of  insanity,  that  hardly 
requires  any  explanation. 


CHAPTER    III. 

PATHOLOGY, 

In  the  definition  of  insanity  adopted  here  the 
pathology  of  insanity  is  expressed;  it  is  a  disease  or 
defect  of  the  brain.  Speaking  more  exactly,  it  may  be 
said  to  be  a  derangement  of  the  functions  of  those  parts 
of  the  brain,  the  centers  of  the  cerebral  cortex  and 
their  connections,  that  are  concerned  in  the  intellectual 
and  emotional  life  of  the  individual.  Taking  all  forms 
of  mental  alienation  into  consideration,  we  have  in  the 
extreme  types  of  idiocy  a  very  obvious  cerebral  defect ; 
the  organ  of  the  mind  is  insufficiently  developed  to 
permit  the  performance  of  its  normal  functions,  and 
the  defect  is  often  a  gross  macroscopic  one,  intelligible 
even  to  the  ordinary  observer  in  the  microcephalism 
and  the  misshapen  cranium  which  correspond  to  the 
expressionless  visage  and  the  purely  animal  propen- 
sities and  behavior.  From  this  extreme  we  have  every 
gradation  in  the  more  or  less  pronounced  type  of 
partial  idiocy  and  imbecility  down  through  the  various 
degenerative  forms  of  alienation  to  the  intellectual 
paranoiac  or  cyclic  case,  in  whom  only  careful  measure- 
ments and  the  observation  of  an  expert  can  detect 
the  stigmata.  In  all  of  these  there  is  a  more  or  less 
pronounced  cerebral  defect;  the  mental  alienation  is 
the  result  of  arrested  or  misdirected  development,  due 
either  to  fatal  congenital  defects,  or  to  those  that, 
existing,  lacked  the  counteracting  influences  of  training 
or  environment.  Not  every  case  of  cerebral  degenera- 
tion tends  inevitably  to  insanity,  but  such  structural 
deficiencies  seriously  handicap  their  bearers  in  the 
difficult  struggle  for  existence,  and  very  often  lead  to 

40 


MICROSCOPIC     CHANGES.  41 

mental  disorder  when  not  obviated  by  care  and  train- 
ing, especially  through  the  critical  developmental 
epochs  of  life.  If  we  were  to  examine  the  inmates  of 
any  large  asylum  and  compare  them  with  an  equal 
number  of  individuals  of  like  social  position  outside 
its  walls,  we  would  probably  be  struck  with  the  exces- 
sive proportion  of  misshapen  crania,  facial,  aural,  and 
other  deformities  in  the  one  class  as  compared  to  the 
other,  taking  each  as  a  whole.  If  we  take  a  special 
group  of  insanities,  the  degenerative  types,  the  para- 
noiacs,  the  hysteric  and  neuropathic  cases  generally, 
only  for  the  comparison,  the  difference  will  be  still 
more  marked.  According  to  Knecht,*  these  degenera- 
tive stigmata  are  four  or  five  times  as  frequent  in  the 
chronic  insane  as  in  normal  individuals.  They  are  the 
external  signs  of  the  insane  predisposition,  and,  as 
Spiller  f  says,  "they  are  related  to  still  further  abnor- 
malities in  the  finer  structure  of  the  brain  that  cannot 
be  detected  by  the  microscope."  It  does  not  follow, 
however,  that  the  reverse  of  this  is  true,  that  the  finer 
structural  defects  connected  with  mental  alienation  are 
necessarily  connected  with  macroscopic  signs.  The 
grosser  abnormalities,  either  in  external  physical  stig- 
mata or  aberration  in  the  cerebral  convolutions,  may 
be  absent  or  so  inconspicuous  as  not  to  be  character- 
istic. This,  it  is  true,  is  only  the  case  in  a  minority 
of  the  insane,  and  more  especially  in  those  in  whom 
no  predisposition  is  known  to  exist.  In  the  not  very 
common  cases  where  there  is  opportunity  for  an 
autopsy  of  acute  insanity,  there  is  usually,  beyond  a 
congestion  and  the  conditions  referable  to  the  disorder 
that  directly  carried  off  the  patient,  nothing  in  the 
naked-eye  findings  that  accounts  for  the  mental  dis- 
order.    Until  within  a  few  years  it  was  certainly  true, 

*Verein  deutscher  Irrenarzte,   Hannover,    1897,   "Neurol.  Cen- 
tralbl.,"  1897,  No.  20. 

t  "  Philadelphia  Med.  Jour.,"  Mar.  12,  1898. 


42  PATHOLOGY. 

as  Spitzka  has  said,  that  in  at  least  40%  of  the  insane 
we  could  find  no  characteristic  lesions  of  their  disease, 
and  in  half  the  remainder  only  such  as  might  also  be 
due  to  other  morbid  conditions.  The  more  recent 
acquisitions  in  the  anatomy  and  physiology  of  the 
nervous  centers  have  nevertheless  opened  up  a  field 
for  rational  speculation,  at  least,  if  they  have  not  fully 
demonstrated  the  basis  of  all  forms  of  insanity.  The 
changes  in  the  nerve-cell  from  fatigue,  and  toxins, 
demonstrated  by  Hodge,  Barker,  and  others,  are 
suggestive  of  the  conditions  in  certain  psychoses; 
and  the  same  is  particularly  true  of  the  theories  of 
Flechsig,  who  finds  the  cerebral  cortex  chiefly  com- 
posed of  associational  or  intellectual  centers  that 
develop  gradually  after  birth  and  are  only  complete 
at  full  maturity.  Their  disorder,  or  that  of  their 
infinitely  ramifying  and  complex  connections,  can 
readily  be  supposed  to  account  for  mental  derange- 
ments, and  it  is  possible  to  build  up  elaborate  theoretic 
explanations  of  the  various  symptoms  on  the  basis  of 
these  findings  and  their  probable  extensions.  Flech- 
sig's  ideas  are,  however,  yet  sub  judice,  and  are  not 
accepted  as  final  by  all  neurologists,  and  any  theory 
based  upon  them  must  be  taken  simply  as  theory — not 
as  established  fact.  This  is  true,  also,  of  the  theory 
of  Dercum,  that  all  types  of  cerebral  derangement 
may  be  caused  by  imperfect  or  failing  contact  of  the 
neurons,  which  are  supposed  by  him  to  be  movable 
in  their  dendritic  extensions. 

It  is  possible,  and  perhaps  one  might  say  probable, 
that  one  or  both  of  these  theoretic  explanations  of 
mental  disorder  may  be  true;  but  at  present  they 
are  imagined,   not  demonstrated,  explanations. 

When  we  come  to  enumerate  the  actual  lesions  that 
have  been  met  with  in  chronic  insanity,  we  find  our- 
selves in  the  presence  of  an  infinite  variety  of  morbid 
conditions,  such  as  might  be  expected  when  we  con- 


ACTUAL    LESIONS.  43 

sider  that  insanity  is  itself  a  disorder  of  functions,  and 
that  it  may  therefore  be  the  result  of  whatever  can 
affect  the  normal  action  of  the  intellectual  and  emo- 
tional cerebral  centers.  The  fact,  also,  that  lost  or 
perverted  function  must  have  its  effects  on  the  organ 
is  also  to  be  borne  in  mind,  and  that  the  lesions  found 
may  be  as  well  the  results  as  the  causes  of  the  insanity. 
Some  of  the  appearances  are,  moreover,  only  the  exag- 
geration of  what  is  often  seen  in  normal  brains,  due  to 
the  more  excessive  and  ill-regulated  excitations  of  the 
insane — and  such,  for  example,  may  be  the  thickening 
and  opacity  of  the  arachnoid,  and  the  extent  and 
abundance  of  the  Pacchionian  granulations.  Others, 
again,  may  be  a  persistence,  and  exaggeration  perhaps, 
of  an  infantile  condition,*  such  as  the  extensive  cranio- 
dural  attachment  sometimes  met  with  that  is  not  appa- 
rently connected  with  acute  inflammatory  processes. 
These  latter  also  leave  traces  in  adhesions  that  are  espe- 
cially notable  in  certain  organic  insanities,  and  general 
paresis  in  particular.  They  are  also  often  met  with  in 
old  cases  of  secondary  dementia,  but  are  less  numer- 
ous and  extensive.  Arachnoid  cysts  and  ecchymoses, 
ossifications  of  the  dura,  miliary  sclerosis  of  the  cortex, 
are  also  conditions  claimed  to  be  rather  frequent  in  old 
cases  of  insanity,  and  atrophy  of  the  brain  is  a  common 
result  of  long-existing  terminal  dementia.  Edema  and 
anemia  are  also  noted  in  certain  cases.  In  organic  and 
senile  insanities,  including  under  these  heads  the  trau- 
matic forms,  we  have,  of  course,  every  possible  lesion 
that  can  derange  the  normal  functioning  of  the  brain. 
The  condition  of  the  vascular  system  is  largely  the 
starting-point  of  these,  and  arterial  disease,  either  as 
atheromatous  degeneration  or  sclerosis,  or  direct  in- 

*This  does  not  refer  to  inflammatory  adhesions,  nor  in  this 
class  of  lesions  do  we  include  those  arrests  of  development  such 
as  we  found  in  idiocy  or  imbecility,  but  simply  to  local  anomalies 
that  are  not  always  incompatible  with  normal  cerebral  action,  but 
which  afford  points  of  weakness  under  favoring  conditions. 


44  PATHOLOGY. 

flammatory  conditions  of  the  vessels  are  often  observed. 
The  lesions  also  indicate  at  times  a  direct  toxic  or 
bacterial  origin,  as  in  acute  delirium,  which  seems  to  be 
sometimes,  at  least,  an  infectious  and  usually  rapidly 
fatal  disorder.  Alzheimer  has  called  attention  to  a 
morbid  proliferation  of  the  glia  cells  and  fibers  as  a 
common  finding  in  different  forms  of  acute  and  chronic 
mental  disorder,  and  holds  that  this  is  the  more  marked 
the  older  and  more  hopeless  the  case. 

In  estimating  the  value  of  any  of  the  pathologic 
findings  in  insanity  a  number  of  points  have  to  be  con- 
sidered. The  fact  that  a  large  proportion  of  the 
lesions  found  are  secondary  to  the  disorder,  and  not  its 
cause,  has  already  been  noted.  This  is  particularly 
true  of  the  microscopic  findings,  and  one  has,  moreover, 
to  sometimes  question  the  methods,  and  query  whether 
some  of  the  apparent  lesions  may  not  be  due  to  reagents 
employed.  Then  the  fact  must  also  be  kept  in  mind 
that  has  been  mentioned  in  a  preceding  chapter,  that 
with  many  of  the  subjects  of  mental  disorder  there  has 
existed  a  predisposition;  they  had  already  unstable 
brains,  ready  for  disordered  function  on  any  provoca- 
tion. It  may  be  said,  indeed,  that  in  acute  insanities, 
as  a  rule,  the  more  minute  and  microscopic  lesions 
are  practically  unknown,  or  at  least  that  they  have  not 
yet  been  fully  and  satisfactorily  demonstrated,  except 
possibly  in  intensely  toxemic  types,  such  as  acute 
delirium  and  paresis;  and  that  in  the  chronic  forms 
they  are  multiform,  and,  except  in  certain  special  types 
that  can  be  better  described  later  in  the  special  patho- 
logic portion  of  this  work,  they  are  hardly  character- 
istic. This,  of  course,  excepts  those  cases  where  there 
are  pronounced  anomalies  of  the  brain,  as  in  idiots, 
and  other  defectives,  and  the  gross  appearances  that 
have  been  mentioned  as  common  in  a  large  number  of 
the  insane,  the  evidences  of  causal  organic  disease, 
traumatisms,  tumors,  etc. 


CHAPTER  IV. 
GENERAL  SYMPTOMATOLOGY. 

The  symptoms  of  mental  disorder  that  especially 
mark  it  as  such  are  chiefly  psychic,  and  this  is  so 
commonly  recognized  that  to  the  average  public  they 
are  the  only  and  exclusive  ones.  There  are,  it  is  true, 
a  large  number  of  physical  phenomena  accompanying 
insanity,  and  some  of  these  are  so  characteristic  of  and 
peculiar  to  the  condition  of  mental  derangement  that 
they  cannot  well  be  overlooked  in  discussing  their 
semeiology.  There  are  also  many  others  that  are  shared 
in  common  by  various  nervous  disturbances,  and  their 
connection  with  insanity  is,  as  it  were,  only  incidental; 
these  may  in  part  also  receive  notice  here.  When  the 
brain  is  diseased,  the  whole  body  suffers;  and  this 
suffering  may  be  through  a  direct  trophic  or  other  in- 
fluence exerted  from  the  great  nerve-center,  or  it  may 
occur  simply  as  a  secondary  result  of  the  mental  de- 
rangement, of  the  want  of  the  conscious  or  the  sub- 
conscious care  that  the  normal  individual  constantly 
exercises  over  his  physical  welfare.  We  can  hardly 
agree  with  Kraepelin  when  he  says  that  all  these  do  not 
belong  to  the  phenomena  of  insanity  as  such,  for  it  is 
impossible  to  completely  sever  the  mental  from  the 
bodily  symptoms,  especially  in  the  disorders  of  percep- 
tion which  are  so  closely  related  to  our  physical  sensa- 
tions. There  are  also  a  large  number  of  bodily  symp- 
toms that  are  almost,  if  not  quite,  peculiar  to  insanity ; 
they  only  occur  in  cases  of  mental  disorder.  While 
some  of  these  are  more  or  less  restricted  to  certain 
forms  or  types  of  insanity,  others  are  so  generally  met 
with  or  so   eccentric   in  their  occurrence   as '  to  well 

45 


4.6  GENERAL    SYMPTOMATOLOGY. 

deserve  notice  in  the  general  as  well  as  the  special 
symptomatology  of  these  disorders. 

Without  committing  one's  self  to  any  special  psycho- 
logic theories,  we  can  divide  the  manifestations  of  mind 
into  four  great  heads:  viz.,  the  sensations,  the  judg- 
ment or  intellect,  the  emotions,  and  the  will.  Under 
the  sensations  must  necessarily  be  included  their  con- 
scious appreciation,  and  the  term  perception  might 
have  been  used,  though  it  would  be  in  some  respects 
undesirable  for  the  purpose,  as  it  has  a  wider  applica- 
tion and  can  be  equally  associated  with  the  feelings  or 
emotions  which  for  convenience  are  here  separately 
considered. 

Sensations,  and  to  some  extent  emotions,  are  the 
starting-point  of  all  mental  activity.  An  individual 
born  without  any  sensory  organs,  were  it  possible  for 
him  to  survive,  could  have  no  mental  development 
whatever.  The  essentials  of  a  sensation,  with  its  con- 
sequent perception,  are  an  end-organ,  a  connecting 
nerve,  and  a  group  of  perceptive  ganglia  or  cells.  In 
considering  mental  symptoms  we  can  neglect  lower 
ganglionic  or  spinal  centers,  and  confine  our  considera- 
tion exclusively  to  those  of  the  cerebral  cortex,  where 
the  mind,  so  to  speak,  takes  cognizance  of  the  message 
from  the  periphery.  Any  of  these  organs  may  be  de- 
ranged, but  in  insanity  it  is  the  alterations  of  the  sense 
perceptions  rather  than  their  suppression  that  has  a 
symptomatic  importance,  and  then  chiefly  only  when 
the  sensation  is  not  only  disordered  or  perverted,  but 
is  so  received  by  the  mind  as  to  affect  or  falsify  the 
judgment.  In  insanity  the  judgment  must  be  in- 
volved in  perceptive  or  sensory  disorders,  and  prac- 
tically therefore  the  mental  division  is  threefold, 
though  for  convenience  a  fourfold  division  is  here 
adopted. 

Growing  out  of  this  fourfold  division  of  mind  we 
have,  as  characteristic  derangements  of  the  perceptions 


DELUSIONS.  47 

and  the  judgment,  delusions,  illusions,  and  hallucin- 
ations. 

Delusions. — A  delusion  is  simply  a  belief  in  the  truth 
of  that  which  is  not  true ;  it  is  a  false  belief.  Delusions 
have  been  and  are  still  considered  as  the  essential 
characteristic  of  insanity,  but  this  can  hardly  be  said 
to  be  true  in  the  sense  that  they  are  at  all  peculiar  to 
insanity.  In  fact,  it  is  one  of  the  most  difficult  of  all 
possible  definitions  to  define  just  what  an  insane  delu- 
sion is.  Beliefs  of  all  kinds  depend  so  much  upon 
training  or  education  and  environment  that  it  is  almost 
impossible  to  say  what  may  not  be  an  individual  or 
general  faith  at  any  one  time.  There  are  a  few  delu- 
sions that  seem  intrinsically  insane,  such  as  a  man's 
believing  himself  the  Deity,  or  thinking  that  he  is 
pregnant  and  about  to  give  birth  to  a  child ;  but  even 
these  by  themselves  alone,  under  certain  conditions, 
would  hardly  be  evidence  of  mental  disease.  It  is  less 
important  to  the  physician  than  the  jurist  to  have  an 
exact  definition.  We  recognize  insanity  by  the  con- 
sensus of  symptoms,  but  in  courts  and  for  legal  purposes 
it  is  often  necessary  to  be  able  to  say  in  at  least  a 
general  way  which  is  an  insane  delusion.  The  following 
will  perhaps  serve  as  well  as  any  other,  though  its 
defects  are  obvious :  An  insane  delusion  is  a  false  belief 
that  is  incompatible  with  the  training,  education,  and 
general  environment  of  the  individual ;  and  moreover 
should  be  as  to  a  matter  of  fact  or  should  be  contrary 
to  the  usual  habit  of  thought  of  the  individual. 

Each  case  must  be  judged  by  itself,  and  what  would 
be  evidence  of  insanity  in  one  would  be  of  no  value  in 
another. 

There  are  certain  characteristic  types  of  delusions 
in  insanity,  however,  and  these  when  recognized  have, 
in  connection  with  other  signs,  an  almost  pathogno- 
monic value.  Such  are  the  persecutory  delusions  of  the 
paranoiac,  the  self-accusatory  ones  of  the  melancholiac, 


48  GENERAL    SYMPTOMATOLOGY. 

and  the  exalted  and  optimistic  notions  of  paresis  and 
some  other  forms  of  insanity.  The  fixed  and  per- 
manent nature  of  some  and  the  changeable  and  un- 
systematized character  of  others  are  also  character- 
istic. The  whole  subject  of  delusions  is  one  that  can 
be  best  treated  in  connection  with  the  separate  forms 
in  which  they  appear  in  the  special  pathology  of 
insanity. 

The  origin  of  insane  delusions  may  be  in  many  ways, 
according  as  the  original  impression  is  made  upon  the 
disordered  and  defective  judgment.  Some  delusions 
are  simply  the  result  of  simple  suggestion  acting  on 
exalted  emotional  conditions  when  judgment  is  in 
abeyance.  Such,  for  example,  are  the  flighty  delusions 
of  the  acute  maniac  and  the  exalted  paretic.  Illusions 
are  responsible  for  some,  hallucinations  for  others,  and 
in  many  cases,  no  doubt,  they  have  their  origin  in 
dreams  or  the  dreamy  states  of  consciousness  of  many 
forms  of  insanity.  In  other  cases  they  arise  from 
excessive  dwelling  of  the  mind  on  single  ideas  and 
suspicions;  they  take  their  start  from  an  egotistic 
misinterpretation  of  facts,  a  sort  of  mental  illusion; 
such,  for  example,  are  often  the  persecutory  delusions 
of  systematized  paranoia.  In  still  other  cases  they  are 
simply  the  result  of  day-dreams  of  an  ill-organized 
intellect,  as  in  the  partial  delusions  of  original  paranoia. 
Whatever  their  origin,  they  are  symptoms  of  defect  of 
intellectual  discrimination  or  judgment;  they  are  the 
symptoms  of  disordered  intellect  par  excellence. 

Illusions. — An  illusion  is  a  false  perception  of  a  real 
impression.  The  object  sensed  is  not  recognized  in  its 
real  character,  but  is  perceived  as  something  else.  A 
familiar  example  would  be  the  mistake  of  taking  a 
crooked  stick  or  a  piece  of  rope  on  the  ground  for  a 
snake,  and  in  this  case  the  natural  dread  of  the  reptile 
aids  in  producing  the  deception.  An  illusion  is  not 
always  or  even  commonly  an  indication  of  insanity; 


ILLUSIONS.  49 

we  are  all  of  us  liable  to  be  deceived  with  these  common 
everyday  impressions,  but  these  false  perceptions  of 
real  sensorial  impressions  are  vastly  more  common  in 
the  insane  than  in  the  sane ;  they  are  in  all  cases  errors 
of  judgment  of  true  sensorial  impressions,  and,  as  has 
been  said,  they  are  delusional  phenomena,  false  beliefs 
based  upon  correct  premises.  The  disordered  condi- 
tion of  the  brain  does  not  permit  its  intellectual  center 
to  exercise  correct  judgment  on  what  the  senses 
normally  bring  to  it. 

Illusions  of  sight  are  the  most  common  in  the  insane, 
and  one  of  the  most  striking  examples  of  this  is  the 
very  frequent  illusion  of  identity.  The  insane  person 
sees  an  acquaintance  and  mistakes  him  for  an  entirely 
different  individual,  or  vice  versa.  In  conditions  of 
great  excitement  almost  everything  that  happens  about 
the  maniac  and  of  which  he  is  rendered  cognizant  by  his 
senses  is  thus  misinterpreted,  and  this  is,  if  we  consider 
it,  readily  seen  to  be  only  an  exaggeration  of  what 
occurs  with  those  who  are  not  insane.  Beard  has 
pointed  out  very  strikingly  how  no  one  in  sudden  panic 
or  in  other  conditions  of  intense  excitement  is  a  com- 
petent witness  as  to  what  he  sees,  and  the  active  maniac 
is  in  a  constant  state  of  mental  excitation  that  vitiates 
his  perception  as  well  as  his  judgment. 

Next  to  illusions  of  sight  come  probably  those  of 
hearing,  and  all  the  senses  may  be  thus  subject  to 
misinterpretations  in  states  of  mental  disease.  A  very 
striking  class  of  illusions  is  that  of  the  internal  or 
visceral  sensations ;  a  vague  bodily  sensation  is  attrib- 
uted to  some  special  cause  altogether  different  from 
the  reality.  These  are  sometimes  indicative  of  local 
visceral  disease;  a  patient  may  complain  of  having  a 
snake  or  some  other  living  thing  in  his  abdomen  from 
the  sensation  aroused,  let  us  say  by  a  colonic  stricture, 
or  some  other  diseased  condition. 

It  is  often  extremely  difficult  to  separate  illusions 


50  GENERAL    SYMPTOMATOLOGY. 

from  delusions,  on  the  one  hand,  and  from  the  con- 
ditions next  to  be  described — namely,  hallucinations. 
An  insane  illusion  is  in  fact  associated  so  universally 
with  a  delusion  that  they  can  hardly  be  considered 
separately ;  and,  on  the  other  hand,  it  is  often  impos- 
sible to  say  where  illusion  ends  and  hallucination 
begins. 

Hallucinations. — A  hallucination  is  a  false  perception 
without  a  material  basis,  not,  like  an  illusion,  merely 
a  misinterpretation  of  a  message  conveyed  to  the  per- 
ceptive centers  by  the  sense  organs.  The  whole  mes- 
sage is,  we  may  say,  a  forgery;  the  consciousness  is 
deceived  into  accepting  as  true  what  does  not  exist. 
The  pathology  of  hallucinations  is  a  difficult  subject  in 
some  respects;  the  problems  it  involves  are  complex 
ones,  but  the  best  explanation  of  them  is  probably  that 
they  are  symptoms  of  excitability  of  cortical  perceptive 
centers,  that  reveals  itself  by  the  external  projection  of 
combinations  of  the  images  that  have  been  stored  up 
from  former  impressions.  A  very  apt  illustration  of  a 
hallucination  and  its  explanation  as  given  here  is  the 
well-known  fact  that  persons  who  have  had  limbs 
amputated  still  have  at  times  sensations  which  they 
refer  to  the  absent  member.  The  limb  is  gone,  and 
therefore  they  cannot  really  feel  it,  but  its  cortical 
sensory  center  remains,  and  cannot  be  altogether  put 
out  of  action ;  hence  the  sensation  of  the  lost  member. 
The  illustration  also  shows  that  hallucinations  are  not 
necessarily  a  symptom  of  insanity;  in  fact,  hallucina- 
tions are  not  infrequently  met  with  in  the  sane,  and 
can  be  readily  produced  under  certain  circumstances. 
They  are,  however,  always  a  sign  of  central  disturbance, 
of  disorder  in  the  cerebral  cortex,  and  have  therefore 
a  special  pathologic  importance;  and  while  they  may, 
and  often  do,  occur  with  perfect  intellectual  integrity, 
their  existence  in  those  who  in  other  ways  also  exhibit 
evidence  of  mental  derangement  is  always  a  matter 


HALLUCINATIONS.  5 1 

for  attention.  Probably  the  most  generally  involved 
of  the  special  senses,  taking  all  forms  of  hallucination, 
sane  and  insane  together,  is  that  of  sight;  but  any  of 
the  senses  can  be  thus  involved,  and  in  the  insane 
every  possible  form  of  hallucination  is  occasionally 
met  with.  As  might  be  understood  from  their  assumed 
pathology,  hallucinations  are  commonly  a  reflex  result 
of  some  peripheral  irritation,  sometimes  a  disease  of 
the  peripheral  organ  of  the  sense  involved,  or  its 
central  conductors;  but  in  other  cases  it  may  be  from 
an  entirely  different  source — some  other  special  sense, 
for  example.  Hallucinations  may  also  be  unilateral, 
and  connected  with  disease  of  the  corresponding  sense 
organ  of  that  side;  and  if  bilateral,  they  may  be  dif- 
ferent on  the  two  sides.  Whether  there  are  hallucina- 
tions of  purely  central  origin  is  a  question  that  has  been 
disputed.  There  is  no  good  reason,  however,  to  assume 
it  impossible  for  excitations  to  arise  in  the  cortical 
centers  themselves,  especially  when  one  takes  into  con- 
sideration the  usual  effects  of  long-continued  use. 
Habit  alone  will  be  sufficient  to  account  for  such,  and 
there  are  cases  enough  where  no  exciting  impressions 
can  be  detected.  Local  cortical  disease  of  irritative 
nature  may  also  be  invoked  as  producing  central 
hallucinations  in  some  cases,  the  center  itself  being 
naturally  involved  in  the  irritation. 

Auditory  Hallucinations. — -The  most  important  class 
of  hallucinations  in  the  insane  are  those  of  hearing. 
They  are  important  not  only  on  account  of  their 
frequency,  but  also  because  of  their  association  with 
especially  dangerous  types  of  mental  disease  and  their 
relation  to  the  prognosis.  They  are  not  very  often 
met  with  in  the  sane,  and  when  they  do  occur,  are 
generally  of  rather  evil  significance.  A  patient  may 
for  a  time  realize  their  unreality,  but  their  persistence 
tends  somewhat  more  than  is  the  case  with  those  of 
sight  to  finally  impress  themselves  upon  his  conscious- 


52  GENERAL    SYMPTOMATOLOGY. 

ness  as  real  and  not  fictitious,  and  to  affect  his  ideas 
and  acts  accordingly.  They  may  occur  simply  as  sub- 
jective sensations  of  noise,  little  differing  from  the 
tinnitus  aurium  in  the  sane,  which  is  hardly  recognized 
as  an  hallucination.  They  are  apt,  however,  to  take 
on  a  special  character,  and  to  be  referred  to  some  ex- 
ternal cause,  though  the  patient  may  be  unable  to 
state  just  what  this  is,  and  can  only  describe  them  by 
imitation  or  onomatopeia.  The  typical  auditory  hal- 
lucination, and  the  one  that  is  most  commonly  recog- 
nized, is  a  verbal  one.  The  patient  hears  voices,  and 
generally  words  expressing  definite  ideas,  though  he  is 
often  unable  to  properly  refer  them  to  any  speaking 
person.  Their  utterances  may  be  agreeable,  but  it  is 
more  often  the  case  that  they  are  abusive,  threatening, 
or  commanding,  and  annoying  or  absolutely  distressing 
to  the  patient.  The  belief  in  their  reality  is  so  general 
that  they  are  a  positive  source  of  danger,  and  some 
experienced  alienists  have  maintained  that  every 
patient  with  hallucinations  of  hearing  must  be  con- 
sidered a  dangerous  lunatic.  That  this  is  invariably 
the  case  may  be  questioned,  but  as  a  general  rule  it 
may  be  said  that  they  are  an  indication  of  possible 
dangerous  tendencies,  and  that  as  a  class  the  patients 
thus  hallucinated  are  to  be  considered  untrustworthy. 
The  reason  of  this  is  obvious :  These  voices  are  direct 
incentives  to  acts,  and  as  their  general  character  is 
abusive  or  malignant,  in  one  way  or  another  it  is  easy 
to  see  how  they  may  give  rise  to  assaults  or  crimes. 
This  is  more  particularly  the  case  when  they  are 
referred  by  the  patients  to  individuals  about  them,  as 
is  sometimes  the  case.  A  rather  rational  epileptic 
patient,  who  was  subject  to  these  hallucinations,  in 
some  of  his  post-epileptic  states  feelingly  expressed  his 
fear  of  their  affecting  his  actions.  He  was  to  a  certain 
extent  conscious  of  their  falsity,  but  he  said  they  came 
upon  him  so  unexpectedly  at  times,  and  when  he  was 


HALLUCINATIONS.  53 

irritably  weakened,  that  he  feared  he  might  even  com- 
mit a  crime  at  their  dictation  or  provocation. 

There  is  a  curious  phenomenon  closely  related  to 
these  hallucinations  that  may  be  considered  here. 
Instead  of  external  sounds  or  voices,  the  patient  may 
have  a  consciousness  of  an  internal  voice  that  may  be 
as  real  to  him  as  any  external  auditory  perception. 
In  this  case  the  word-center  in  the  brain  is  involved, 
and  Seglas  has  given  to  this  phenomenon  the  name  of 
psychomotor  hallucination. 

Auditory  hallucinations  are  not  confined  to  those 
who  are  sound  in  hearing;  the  deaf  insane  often  have 
them,  and  also  the  corresponding  inner  hallucinations. 
It  is  said  that  Beethoven  in  his  later  days  still  com- 
posed music,  and  though  his  hearing  was  lost,  he  had, 
as  it  were,  a  perfect  subjective  sensation  of  hearing  his 
own  works.  It  is  quite  possible  to  believe  that  this 
power  of  auditory  mental  imagery  was  so  great  that  it 
might  culminate  in  an  actual  hallucination  of  hearing 
his  own  music. 

Patients  sometimes  complain  of  mind  readers  re- 
peating their  thoughts  which  they  believe  they  hear 
uttered  immediately  as  they  arise,  and  this  has  been 
called  the  "echo  of  thought." 

The  chief  characteristic  of  auditory  hallucinations  is 
the  faith  in  their  reality  on  the  part  of  the  subjects,  and 
the  consequent  effects  on  conduct.  It  is  said  by  Regis 
that  the  subjects  of  these  have  a  special  physiognomy, 
showing  itself  in  a  wider-open,  brilliant  eye,  and  a 
general  expression  as  if  they  are  not  taking  note  of 
things  directly  about  them.  Be  this  as  it  may,  there 
is  usually,  at  least  to  long  observation,  some  peculiarity 
of  manner  that  will  betray  them — a  listening  attitude, 
sometimes  a  movement  of  the  lips  as  if  talking  to  some 
one,  or  some  other  sign  of  attention  to  these  subjective 
but  externally  projected  sensations. 

Visual     Hallucinations. — Hallucinations     of     sight, 


54  GENERAL    SYMPTOMATOLOGY. 

while  less  common  in  the  insane  than  those  of  hearing, 
rank  next  to  them  in  frequency.  They  are  especially 
characteristic  of  certain  toxic  forms  of  mental  derange- 
ment; acute  alcoholism,  for  example,  and  hashisch 
intoxication,  which  is  often  a  continued  series  of  visual 
hallucinations.  They  occur  also  very  largely  in  post- 
febrile insanity  with  other  sensory  hallucinations,  and 
are  common  in  pre-  and  post-epileptic  conditions  and 
other  neuropathic  forms  of  mental  disorder. 

They  are  sometimes  of  an  agreeable  character,  espe- 
cially in  the  milder  delusions,  and  in  some  chronic 
cases,  but  in  pronounced  insanity  of  the  acute  type 
they  are  more  apt  to  be  disagreeable  and  terrifying. 
This  is  their  character,  as  is  well  known,  in  delirium 
tremens,  while  in  hashisch  intoxication  the  reverse  is 
apt  to  be  the  case. 

The  significance  of  visual  hallucinations  is  much  less 
serious  than  that  of  those  of  hearing.  They  occur 
more  generally  in  acute  and  curable  forms  of  derange- 
ment, and  while  they  may  give  rise  to  excitement  and 
agitation,  they  are  not,  as  a  rule,  incitants  to  dangerous 
acts. 

Hallucinations  of  Smell  and  Taste. — These  are  also 
frequently  met  with,  though  less  common  than  those 
already  mentioned.  Patients  frequently  complain  of 
foul  odors,  of  gases  being  forced  into  their  sleeping 
apartments;  and  such  complaints  are  not  uncom- 
mon with  certain  forms  of  persecutory  delusions, 
which  are  largely  based  upon  them.  They  think  they 
taste  poison  or  defilements  in  their  food,  and  base 
whole  persecutory  delusions  on  these  symptoms. 
They  are  therefore  more  commonly  associated  with  the 
dangerous  forms  of  insanity,  and  in  this  regard  their 
significance  is  like  that  of  auditory  hallucinations.  A 
patient  with  gustatory  or  olfactory  hallucinations  is 
liable  to  commit  violence,  and  is  therefore  to  be 
generally  considered  dangerous. 


DISTURBANCES    IN    THE    EMOTIONAL    SPHERE.         55 

Genital  Hallucinations . — In  considering  the  sexual 
feeling  as  a  sixth  special  sense,  we  find  it  also  subject 
to  hallucinations,  especially  in  insane  females,  who 
often  have  delusions  of  being  violated  or  sexually 
abused,  based  on  these  false  sensations.  They  are 
rarely  of  a  pleasant  nature,  it  would  seem,  and  they 
may  be  the  basis  of  dangerous  delusions. 

Hallucinations  of  Other  Senses. — The  general  tactile 
sense  is  not  infrequently  involved  in  insane  hallucina- 
tions. The  patients  complain  of  various  uncomfort- 
able sensations,  of  insects  crawling  over  them,  of 
electricity,  etc.  It  is  not  an  uncommon  thing  in 
asylums  to  hear  complaints  of  electric  shocks  and 
batteries  placed  under  the  bed,  or  so  arranged  as  to 
play  upon  the  patients  in  their  rooms  at  night.  Some- 
times they  experience  a  feeling  of  defilement,  and 
think  they  cannot  too  frequently  cleanse  themselves, 
their  persons,  their  clothing,  and  their  rooms.  Occa- 
sionally also  we  meet  with  cases  of  hallucinations  of  pain 
and  heat  senses ;  patients  complain  of  being  burned  and 
otherwise  injured,  and  have  full  faith  in  their  false  sen- 
sations. In  fact,  there  is  no  possible  modification  of  the 
special  or  general  sensibility  that  may  not  be  affected 
in  this  way. 

Disturbances  in  the  Emotional  Sphere. — The  most 
commonly  met  with  emotional  disturbances  in  insanity 
are  melancholy,  or  emotional  depression,  and  the 
reverse  condition  of  hilariousness  or  exaltation.  The 
latter  is  met  with  in  maniacal  conditions  as  an  incident 
to  the  general  exaltation  of  feeling  and  intellection  in 
those  states.  Melancholy,  or  emotional  depression,  is 
a  very  important  symptom  in  insanity;  the  most 
prominent  one,  in  fact,  in  several  forms  of  mental  dis- 
ease. It  may  be  simple  mild  depression ;  the  patient 
feels  bad,  and  cannot  explain  the  reason  or  divest  him- 
self of  the  feeling.  In  other  cases  it  becomes  more 
intense,  and  amounts  to  actual  agony,  and  shows  itself 


56  GENERAL    SYMPTOMATOLOGY. 

not  only  in  the  patient's  manner  and  physiognomy, 
but  in  his  actions,  producing  the  so-called  r aphis 
melancholicus,  or  agitated  melancholia.  All  of  the 
special  emotional  excitations  can  also  be  produced  in  a 
more  or  less  exaggerated  form;  the  feelings  of  love, 
anger,  jealousy,  fear,  with  their  accompanying  symp- 
toms, are  frequently  experienced  and  revealed  to 
observation. 

The  opposite  state  to  melancholia,  exaltation,  is  also 
frequent  in  insanity,  and  is  more  strikingly  apparent 
in  maniacal  conditions,  in  which  it  may  range  in  degree 
from  mild  emotional  and  intellectual  erethism  to  com- 
plete mania  with  absolute  incoordination  of  all  the 
psychic  functions.  Again,  we  have  in  some  forms  of 
insanity  every  degree  of  mental  suppression  or  inhibi- 
tion; in  some  cases  the  patient  may  have  apparently 
no  feelings  good  or  bad,  and  no  intellectual  action 
whatever.  Mental  inhibition  of  every  grade  from 
simple  inability  to  fix  attention  (aprosexia)  to  complete 
intellectual  and  emotional  eclipse  may  exist. 

There  is  a  special  class  of  symptoms  sometimes 
associated  and  classed  with  these  emotional  disturb- 
ances that  calls  for  special  mention  here ;  such  are  the 
so-called  instinctive  insanities,  in  which  the  patient 
shows  aberrations  in  the  moral  or  ethical  side  of  his 
nature,  or  in  the  sense  of  propriety  and  decency.  The 
patient  may  apparently  lose  all  the  check  of  conscience 
and  deliberately  violate  moral  law  in  every  possible 
way.  He  may,  and  this  is  the  common  rule,  become 
abnormally  egoistic,  or  much  more  rarely  the  altruistic 
feeling  may  predominate.  Another  common  aberra- 
tion is  apathy  or  indifference  without  positive  tenden- 
cies either  good  or  bad.  Under  this  head  may  be 
included  the  phenomena  of  what  is  called  the  insanity 
of  acts  or  conduct  in  which  the  patient  seems,  while 
reasoning  correctly,  to  be  incapable  of  so  directing  his 
behavior  as  to  make  it  consistent  with  what  should  be 


DISORDERS    OF    THE    WILL.  57 

expected  of  him  in  his  condition  and  circumstances  of 
life. 

The  instinct  of  self-preservation  is  often  lost  or 
modified,  and  many  self -mutilations  and  suicides  in  the 
insane  are  due  to  indifference  or  apathy  in  this  regard 
instead  of  intense  depression  and  dread  of  life.  The 
nutritional  instinct  is  very  frequently  lost  or  perverted ; 
there  is  a  complete  paralysis  of  appetite  and  indifference 
to  food,  and  many  striking  perversions  of  appetite  are 
extremely  common  in  the  insane.  The  reproductive 
instinct  also  suffers;  it  may  be  lost  or  suppressed,  as 
in  many  depressed  conditions,  or  it  may  be  exalted, 
as  is  commonly  the  case  to  some  extent  in  the  opposite 
states  of  mind.  Its  perversions  form  a  whole  class  of 
aberrations,  mostly  on  the  borderland  of  insanity,  that 
have  received  special  attention  of  later  years  by  Krafft- 
Ebing,  Tarnowsky,  Moll,  Ellis,  and  others.  In  the 
actually  insane,  especially  in  asylum  inmates,  these 
are,  if  anything,  less  noticeable  than  amongst  sexual 
perverts  outside. 

These  special  forms  will  be  more  fully  considered  in 
the  special  part  of  this  work  when  treating  of  certain 
types  of  moral  and  emotional  insanity. 

There  may  be  also  an  insanity  of  speech,  entirely 
out  of  proportion  to  the  evidences  of  mental  derange- 
ment as  shown  in  actions;  an  absolute  incoherence, 
that  can  best  be  explained  theoretically  by  a  special 
derangement  of  the  speech  centers  to  a  greater  extent 
than  is  shared  by  the  rest  of  the  brain. 

Disorders  of  the  Will. — The  will  may  be  affected  in 
insanity  either  by  exaggeration  or  diminution  in  the 
power  of  willing  or  by  its  complete  abolition.  The 
weakness  of  will-power  is  noticeable  in  many  depressive 
states.  The  patient  feels  a  lack  of  energy,  is  unable 
to  do  what  he  ought  to  do,  either  through  a  painful 
sense  of  weakness  or,  it  may  be,  an  inability  to  resist 
what    he    may    know    to    be    illusional    conceptions. 


58  GENERAL    SYMPTOMATOLOGY. 

Absolute  aboulia  or  lack  of  will-power  is  common  also 
in  certain  depressed  conditions,  especially  those  due  to 
exhaustion  and  certain  neurasthenic  forms  of  insanity. 
This  special  form  of  defect  is  best  seen  in  the  lack  of 
resistance  to  what  are  called  morbid  impulses,  or  im- 
pulsiveness, and  to  imperative  conceptions  or  delusive 
ideas  which  the  patient  may  recognize  as  such  but 
cannot  resist.  One  of  the  most  noticeable  instances 
of  this  form  of  mental  defect  in  what  is  perhaps  con- 
sidered as  absolute  insanity  is  seen  in  the  so-called 
tics,  the  <;latah"  of  the  Malays  or  the  "myriachit"  of 
the  Siberians.  In  these  conditions  at  the  mere  sugges- 
tion of  an  act  the  individual  is  irresistibly  impelled  to 
its  execution,  even  though  it  may  be  strongly  against 
his  will.  Sudden  impulses  occur  in  normal  individuals, 
and  often  these  are  of  an  insane  character;  the}"  are 
tempted  or  it  is  suggested  to  them  to  do  something 
ridiculous,  immoral,  or  improper,  but  with  a  normally 
constituted  person  it  goes  no  further.  With  the 
weakened  will-power,  however,  of  insanity  of  certain 
types,  to  suggest  the  act  is  to  insure  its  execution ;  and 
many  of  these  strange  performances  are  simply  the 
result  of  the  auto-suggestion  that  might  occur  to  any 
one.  A  delusion  or  hallucination  may  also  be  the 
suggestion  of  these  acts  of  the  patient,  and  that  is  the 
reason  largely  why  they  are  so  dangerous.  A  fixed 
idea  or  imperative  conception  is  one,  generally  more 
or  less  delusive,  that  the  patient  cannot  banish  from 
his  mind,  let  him  will  it  ever  so  strongly.  This  idea 
controls  their  actions  and  thoughts  and  tyrannizes 
over  them.  They  sometimes  occur  suddenly  without 
any  direct  connection  with  the  line  of  thought  then 
going  on.  They  seem  to  be  something  like  spontaneous 
explosions  in  the  nervous  system  concerned  in  intel- 
lection. While  they  may  occur  in  persons  not  actually 
insane,  in  that  case  they  are  resisted;  the  will-power 
of  the  individual,  though  it  may  be  somewhat  dimin- 


DISORDERS    OF    THE    CENESTHESIS.  59 

ished  to  let  them  make  any  impression  whatever,  is 
still  sufficient  to  prevent  their  controlling  him. 

A  large  number  of  so-called  forms  of  insanity  have 
been  based  upon  these  morbid  impulsions,  which  are 
now  recognized  as  only  symptoms  of  a  general  condition 
of  weakened  will-power;  such,  for  example,  are  the 
well-known  kleptomania  or  tendency  to  steal,  which  is 
so  common  a  text  for  certain  medicolegal  writers; 
pyromania,  or  tendency  to  incendiarism,  etc. ;  and  the 
various  phobias,  such  as  agorophobia,  or  fear  of  open 
spaces;  claustrophobia,  or  fear  of  confinement  or  close 
spaces,  and  many  others.  All  these  are  neurasthenic 
symptoms,  which  may  occur  to  some  extent  amongst 
the  sane,  but  are  still  more  frequent  and  formidable 
when  the  will-power  has  been  reduced  by  actual 
insanity. 

Disorders  of  the  Cenesthesis. — Before  closing  this 
chapter  on  the  psychic  symptoms  of  insanity  a  word 
should  be  said  on  the  alterations  of  the  general  feeling, 
or  cenesthesis.  This  may  be  affected  chiefly  in  two 
ways,  either  by  exaltation  or  depression.  It  may  be 
an  increase  of  the  intensity  of  consciousness  or  sense  of 
being,  the  patient  feels  himself  to  be  peculiarly  alive 
and  the  intellect  much  more  active,  emotions  more 
excited,  and  yet  this  is  different  entirely  from  the 
hilarious  excitement  which  has  already  been  mentioned 
under  the  name  of  exaltation,  though  it  is  frequently 
its  accompaniment.  The  condition  is  one  that  is 
characteristic  of  acutely  maniacal  states,  and  in  the 
simple  or  milder  form  of  mania  may  be  almost  the  only 
symptom.  The  patient  is  intellectually  excited ;  thinks 
more  rapidly  and  clearly,  but  probably  less  consecu- 
tively; the  inhibition  is  somewhat  lessened,  and  the 
moral  sentiments  generally  suffer  accordingly.  The 
condition  will  be  more  fully  described  in  treating  of 
that  special  syndrome  of  insanity. 

Depression,  on  the  other  hand,  as  distinguished  from 


60  GENERAL    SYMPTOMATOLOGY. 

the  emotional  depression  of  melancholia,  consists  in  a 
lowering  of  the  sense  of  conscious  being,  of  intellectual 
activity,  and  the  intensity  of  the  feelings.  It  is  the 
characteristic  type  of  certain  forms  of  acute  dementia, 
and  is  often  confounded  with  melancholic  depression, 
which  it  externally  often  strongly  resembles.  The 
mental  condition,  however,  is  rather  one  of  indifference 
than  of  emotional  depression. 

The  disorders  of  memory  are  closely  allied  to  those 
of  intellection,  and  where  thought-power  fails,  memory 
is  apt  to  fail  also.  There  may  be,  of  course,  a  complete 
loss  of  memory,  amnesia  affecting  limited  periods  or 
the  total  past,  and  there  is  apt  to  be  loss  of  memory  of 
periods  of  excessive  excitement,  though  this  is  not  in- 
variably the  case.  A  very  profound  degree  of  apparent 
dementia  is  not  inconsistent  with  an  almost  perfect 
retentional  recollection  of  events.  There  are  patients 
who  appear  to  be  unable  to  utter  a  rational  sentence, 
who  yet  have  almost  perfect  remembrance  of  events. 
These,  however,  are  exceptional  cases.  In  stuporous 
conditions  there  is  apt  to  be  a  loss  of  recollection,  and 
the  same  is  true  to  some  extent  in  agitated  melancholia. 
The  recollections  of  patients  of  their  insanity  are  apt 
to  be  perverted  even  after  a  complete  recovery,  and 
many  cases  occur  in  which  events  that  never  happened 
are  remembered  as  realities.  Cases  of  temporary 
amnesia  are  common  in  epileptic  insanity,  and  this  has 
been  the  basis  of  a  very  generally  accepted  opinion  that 
unconsciousness  exists  in  these  conditions;  in  fact, 
neither  unconsciousness  nor  amnesia  is  an  essential 
characteristic  of  any  epileptic  condition. 

A  complete  loss  of  memory  for  even  most  recent 
occurrences,  with  apparently  unimpaired  intellection 
as  far  as  it  is  compatible  with  such  a  state,  is  sometimes 
observed  in  asylums,  but  such  cases  are  very  rare,  and 
have  not  been  specially  classified.  A  loss  of  the  sense 
of  personal  identity  is  an  occasional  symptom  of  in- 


DISORDERS    OF    THE    CENESTHESIS.  6l 

sanity.  We  sometimes  meet  in  asylums  with  patients 
who  speak  of  themselves  invariably  in  the  third  person, 
and  who  may  be  considered  to  be  suffering  from  a 
defect  of  consciousness  that  disables  them  from 
properly  appreciating  their  own  existence.  It  is  a 
rather  complex  psychic  state,  and  might  be  considered 
as  a  delusion  on  a  mere  superficial  view ;  but  it  appears 
on  closer  observation,  generally  at  least,  to  be  some- 
what different  from  a  mere  belief;  it  has  its  grounding 
in  the  self -feeling,  or  rather  lack  of  it,  of  the  individual. 
The  unconscious  logical  processes  that  form  the  basis 
of  consciousness  are  at  fault.  This  symptom  is  not 
very  frequent,  and  has  not  been  fully  studied  by 
alienists,  but  it  occurs,  and  is  interesting  and  sugges- 
tive, and  should  be  mentioned  in  this  place.  This  is 
not  what  is  commonly  called  double  consciousness, 
which  consists  in  the  occurrence  of  non-synchronous 
separate  psychic  states  with  more  or  less  complete 
amnesia  of  each  other.  The  subject  of  this  condition 
appears  to  be,  and  is,  subjectively  two  different  persons 
at  different  times,  and  while  in  one  may  have  no  recol- 
lection of  the  other.  These  conditions  are  curious,  but 
are  not  so  commonly  observed  in  actual  insanity  as  in 
certain  not  perfectly  understood  pathologic  states  that 
are  not  usually  reckoned  as  full-fledged  mental  de- 
rangement. 

It  may  be  said  that  the  insane,  much  more  largely 
than  is  generally  supposed  to  be  the  case,  have  a 
certain  appreciation  of  their  mental  condition,  and  a 
knowledge  of  this  fact  judiciously  used  is  very  im- 
portant in  their  examination. 


CHAPTER  V. 
GENERAL  SYMPTOIVLATOLOGY  (Continued), 

The  bodily  symptoms  associated  with  insanity  are 
naturally  exceedingly  numerous,  and  many  of  them 
are  so  incidental  and  non-characteristic  as  to  only 
require  mention  most  appropriately  in  connection  with 
the  special  type  of  mental  disease  in  which  they  occur. 
Others,  however,  are  so  important,  or  so  character- 
istic, that  they  well  deserve  a  chapter  on  general 
symptomatology  for  their  description. 

We  will  take  up,  mainly  in  the  order  of  their  impor- 
tance, the  most  prominent  of  these,  without  regard  to 
their  direct  relations  to  each  other  or  to  pathologic 
processes. 

Disorders  of  Sleep. — The  disturbances  of  sleep  take 
first  rank  in  the  physical  phenomena  of  mental  dis- 
orders. They  are,  (i)  insomnia,  which  is  a  character- 
istic symptom  in  by  far  the  larger  proportion  of  cases 
of  acute  insanity.  It  is  met  with  especially  in  maniacal 
conditions,  hardly  less  frequently  in  melancholic 
states,  and  is  a  specially  characteristic  feature  of  the 
excited  period  of  the  circular  insanities.  The  insomnia 
may  be  due  to  the  irritability  of  these  conditions,  and 
thus  afford  a  valuable  therapeutic  indication,  but  inas- 
much as  we  do  not  know  very  perfectly  the  exact 
physiology  of  sleep,  it  is  impossible  to  say  what  the 
mechanism  of  the  symptom  is  in  some  of  these  dis- 
orders. It  is  very  common  in  the  prodromal  periods 
of  acute  insanity,  and  may  be  considered  a  threatening 
symptom,  especially  in  those  who  are  predisposed,  by 
heredity  or  otherwise,  to  mental  disorders.  It  is  re- 
markable to  what  extent  sleeplessness  is  sometimes 

62 


DISORDERS    OF    SLEEP.  63 

endured  by  the  insane.  In  acutely  maniacal  condi- 
tions they  sometimes  pass  a  number  of  days  without 
any  apparent  sleep  whatever,  and  in  certain  circular 
cases  it  is  hard  to  say  when  the  patient  sleeps  at  all 
during  the  excited  stage.  In  one  particular  case  the 
patient  was  constantly  active  for  nearly  six  weeks,  and 
in  another,  which  came  under  the  observation  of  one 
of  the  writers,  about  ten  days  of  apparent  complete 
sleeplessness  alternated  with  an  equal  period  of  stupor. 
There  are  probably  in  such  extreme  cases  momentary 
relapses  into  slumber,  which  are  overlooked,  but  the 
amount  of  sleep  obtained  must  be  exceedingly  small. 

With  lack  of  sleep  there  seems  to  be  little  compara- 
tive deterioration  of  the  general  physical  condition; 
the  patients  often  keep  well  nourished,  and  show  no 
serious  symptoms  of  exhaustion.  In  fact,  they  seem 
to  become  accustomed,  or  acclimated,  to  this  condition, 
and  to  make  up,  at  least  in  some  cases,  by  a  prolonged 
period  of  stupor,  or  somnolence,  for  the  lack  of  slumber 
which  they  have  experienced. 

2.  Somnolence. — A  tendency  to  sleep,  aside  from  the 
cases  just  described,  is  often  noticed  in  some  conditions 
of  general  paralysis,  and  occasionally  in  other  forms  of 
insanity.  Its  diagnostic  or  pathologic  importance  is, 
however,  very  much  less  prominent,  and  it  need  not 
be  further  mentioned  here. 

j.  Disturbances  of  sleep,  in  the  way  of  restlessness, 
dreams,  and  somnambulism,  are  frequently  met  with. 
Many  patients  especially  have  frightful  or  alarming 
dreams,  which  are  often  the  basis  of  a  delusion.  Others 
are  readily  affected  in  their  sleep  by  external  conditions 
of  which  they  are  apparently  not  aware.  Thunder- 
storms, changes  of  the  weather,  etc.,  sometimes  are 
causes  of  later  disturbance,  when  they  have  occurred 
during  the  patient's  slumber.  We  have  known  a 
number  of  insane  patients  who  were  decidedly  worse 
after  a  thunder-storm  which  occurred  during  the  night, 


64  GENERAL    SYMPTOMATOLOGY. 

of  which  they  were  unconscious,  probably  through 
some  disturbance  of  their  sleep,  without  its  having 
been  completely  destroyed. 

Disorders  of  Nutrition. — Nutrition  generally  suffers 
in  acute  insanity,  but  not  always  to  the  extent  that 
might  be  looked  for.  The  absence  of  the  instinct  of 
nutrition  has  already  been  mentioned,  but  besides  this 
there  are  many  other  ways  in  which  it  is  disturbed. 
In  conditions  of  great  excitement,  intellectual  and 
motor,  the  waste  is  necessarily  large,  and  is  rarely  fully 
made  up  for  by  the  assimilation.  There  is,  therefore, 
in  such  conditions  a  decrease  of  weight,  and  sooner 
or  later  a  gradual  failure  of  the  vital  powers,  which,  if 
long  enough  continued,  must  lead  to  the  final  exhaus- 
tion of  the  patient.  With  convalescence  there  is 
generally  an  increase  in  nutrition.  The  patient  takes 
on  flesh  to  make  up  for  what  he  has  lost.  When  this 
occurs,  however,  without  corresponding  mental  im- 
provement, it  is  an  indication  that  the  case  is  passing 
into  the  chronic  stage,  therefore  an  unhopeful  sign. 
Patients  refuse  food  not  only  from  a  lack  of  the  instinct 
of  nutrition,  but  from  a  complete  loss  of  appetite,  and 
often  from  delusions,  fears  of  poisoning,  etc. 

In  connection  with  this  should  be  mentioned  the 
disorders  of  digestion,  which  are  very  common,  espe- 
cially in  depressed  conditions,  and  the  very  general  and 
exceedingly  important  symptom  of  constipation,  which 
is  one  of  the  most  serious  of  the  conditions,  and  goes  to 
an  extent  which  would  hardly  be  realized  by  those 
unacquainted  with  these  cases.  This  reacts  badly  on 
the  nervous  system,  not  only  through  the  mechanical 
overloading  and  sympathetic  disturbance  that  is  in- 
duced, as  suggested  by  Schroeder  van  der  Kolk,  but 
also  through  the  reabsorption  of  intestinal  poisons  and 
ptomains.  The  relief  of  this  condition  has  often  a  vital 
effect  on  the  mental  condition,  which  will  be  more 
fully  described  in  the  chapter  on  general  therapeutics. 


SECRETIONS.  65 

Secretions. — The  secretions  are  liable  to  be  more  or 
less  extensively  altered  in  mental  diseases,  and  in  some 
of  them  the  changes  are  rather  characteristic.  The 
perspiration  is  apt  to  be  suppressed  in  many  forms  of 
insanity;  a  hard,  dry  skin  in  many  cases  of  melan- 
cholia is  especially  noticeable.  It  is  apt  to  be  exces- 
sive in  certain  other  forms,  like  acute  rheumatic  in- 
sanity. It  is  said  that  the  insane  have  often  a 
peculiar  sour  smell,  which  is  distinctly  recognized 
as  a  symptom  of  the  condition,  but  this  is  not  so 
true  as  is  generally  supposed.  Personal  neglect  and 
dirty  habits  have  more  to  do  with  the  odor  of  the 
insane  than  any  special  character  of  the  secretions,  in 
most  cases.  In  acute  melancholia  the  lachrymal  secre- 
tion is  often  lacking,  the  patients  are  not  able  to  weep, 
and  its  reappearance  is  sometimes  a  sign  of  improve- 
ment. The  salivary  secretion  is  apparently  very  much 
affected  in  many  forms  of  insanity.  The  patients  sit 
and  drool  from  the  mouth  a  continuous  stream  of 
saliva,  so  that  sometimes  in  inactive  cases  a  large 
quantity  could  be  collected  in  a  short  time.  This  is 
especially  true  in  some  forms  of  dementia,  and  in 
certain  types  of  chronic  insanity.  Whether  there  is 
an  actual  increase  to  the  extent  that  is  apparent  is 
not  always  beyond  question,  for  the  natural  flow  of 
saliva  is  large;  but  that  it  is  very  markedly  increased 
in  some  cases  is  certainly  undeniable,  and  this  forms 
a  very  striking  symptom,  though  not  particularly 
important  in  regard  to  its  significance  in  very  many 
cases. 

Menstruation  is  usually  disordered  in  insanity,  and 
quite  commonly  suppressed.  This  is  particularly  true 
in  the  acute  cases;  in  chronic  insanity  it  may  not  be 
affected. 

The  condition  of  the  blood,  the  urine,  and  other 
fluids  of  the  body  have  been  more  or  less  studied  in  the 
insane,  but  the  importance  of  the  changes  observed  is 
5 


66  GENERAL    SYMPTOMATOLOGY. 

not  altogether  satisfactorily  determined.  Many  of 
them  are  clearly  symptomatic  of  the  condition,  and 
would  occur  with  equal  states  of  motor  activity  and 
nutrition.  The  epileptics  have  possibly  been  the  most 
carefully  studied  in  this  regard,  the  toxicity  of  the 
urine  and  perspiration,  condition  of  the  blood,  etc. 

The  conditions  of  the  urine  should  always  be  investi- 
gated in  cases  of  insanity,  as  this  excretion  is  so  apt 
to  be  an  index  of  bodily  disorders  that  may  have  an 
influence  on  the  mental  disease.  The  changes  it  shows 
may  be  entirely  secondary  and  unimportant,  but,  on 
the  other  hand,  one  may  at  times  be  able  to  obtain 
important  indications  for  treatment.  Klein  *  found 
in  some  two  hundred  insane,  six  cases  with  depressed 
symptoms  with  excess  of  oxalates  in  the  urine,  and 
treatment  directed  to  this  symptom  appeared  to  be  in 
two  the  starting-point  of  recovery.  As  a  rule,  the 
changes  from  the  normal  will  be  unimportant,  but  in 
some  cases  they  may  be  usefully  significant.  Albumin 
is  not  often  found  in  ordinary  cases  of  insanity,  not- 
withstanding the  fact  that  some  degree  or  form  of 
kidney  derangement  is  almost  the  rule. 

The  study  of  the  blood  is  also  of  value,  as  it  may 
also  reveal  metabolic  conditions  calling  for  or  guiding 
treatment.  The  exact  relation  between  the  blood 
changes  observed — solvent  resistance  of  red  globules 
(isotony),  reductions  of  hemoglobin,  alkalinity,  etc. — 
and  the  insanity  is  not  always  clear;  but  anemic  and 
chlorotic  conditions  may  have  a  practical  significance. 

Reflexes. — The  condition  of  the  reflexes  in  insanity 
largely  depends  on  coarse  organic  disease  accompanying 
or  causing  it,  or  upon  a  general  hyperexcitability  that 
may  exist.  Thus  we  have  the  various  alterations  of 
the  ocular  muscular  reflexes  in  general  paralysis  of  the 
insane,  and  in  organic  insanity  from  various  causes. 
We  have  exaggerated  reflexes  in  certain  neurasthenic 

*"N.  Y.  Med.  Jour.,"  Mar.  18,  1899. 


TROPHIC    CHANGES.  67 

types  of  mental  disorder,  and  have  them  retarded  or 
suppressed  in  certain  forms  of  depressed  mental  con- 
ditions. Some  of  the  deep  reflexes,  like  that  of  the 
knee,  have  been  extensively  tested  and  written  upon; 
their  importance  is  more  in  relation  to  the  accompany- 
ing organic  disease  than  to  the  insanity.  The  pupil- 
lary reflexes  have  been  also  much  studied,  especially  in 
paresis,  where  the  Argyll-Robertson  pupil  is  common, 
though  not  so  invariably  met  with  as  some  have  held. 
They  are  of  value,  like  the  knee  reflex,  as  indications  of 
the  organic  disease.  We  have  seen  in  a  few  cases  a 
paralysis  of  the  accommodation  to  convergence  in 
paresis ;  and  a  similar  observation  has  been  made  by 
Dotto. 

Trophic  Changes. — Trophic  disorders  of  a  peculiar 
type  have  long  been  recognized  as  occurring  in  certain 
forms  of  insanity;  the  most  prominent  one  of  these  is 
probably  othematoma,  or  the  so-called  insane  ear. 
This  consists  of  a  blood  tumor  of  the  external  ear,  as 
its  name  would  imply,  and  is  usually  credited  with 
being  the  result  of  traumatism,  and  therefore  an  indi- 
cation of  violence  or  bad  treatment.  There  is  little 
doubt  that  the  exciting  cause  is  often  a  slight  trau- 
matism, but  back  of  this  is  always  the  depraved 
physical  condition  of  the  patient  that  renders  the  pro- 
duction of  such  a  tumor  possible,  and  this  is  almost 
exclusively  seen  in  certain  forms  of  insanity  with  pro- 
found systemic  disturbance.  Epilepsy,  acute  mania 
of  the  more  pronounced  type,  chronic  mania,  melan- 
cholia with  excitement,  and  general  paralysis  are  the 
forms  in  which  it  is  most  commonly  observed.  The 
left  ear  seems  to  be  more  usually  affected  than  the 
right,  and  there  are  reasons  to  believe  that  it  may  occur 
entirely  independent  of  any  actual  traumatism  what- 
ever. It  is  not  peculiar  to  the  insane,  but  it  is  so  rare 
in  other  conditions  that  its  existence  has  even  been 
denied.     It  occurs  frequently  in  idiots,  and  in  all  cases 


68  GENERAL    SYMPTOMATOLOGY. 

its  occurrence  is  considered  as  an  unfavorable  sign, 
though  it  is  by  no  means  correct  to  say  that  it  cannot 
occur  with  subsequent  perfect  recovery.  It  sometimes 
has  been  observed  in  both  ears  in  patients  who  have 
made  apparently  a  good  recovery.  As  far  as  the 
tumor  itself  is  concerned,  it  almost  invariably  subsides, 
but  leaves  a  very  marked  deformity. 

Another  peculiar  trophic  disturbance  which  is  met 
with  not  only  in  insanity  with  serious  organic  disease, 
but  also  in  conditions  where  such  cannot  be  proved  to 
exist,  is  the  so-called  decubitus,  or  bed-sore.  These 
are  most  common,  it  is  true,  in  paretics,  but  they  may 
occur  in  very  acute  cases  of  mania  or  melancholia, 
where  there  is  a  profoundly  depressed  condition  of 
nutrition.  They  have  been  known  to  occur  among  the 
very  earliest  symptoms  in  an  exhaustive  delirious 
melancholia,  and  to  continue  through  the  course  of  the 
disease,  and  to  be  one  of  the  most  formidable  of  the 
physical  symptoms  to  be  combated  in  the  exhausted 
condition  of  the  patient.  The  ordinary  type  of  bed- 
sore in  paresis,  for  example,  is  a  simple  slough,  which 
may  later  become  a  deep  ulcer ;  but  in  these  acute  cases 
it  may  form  a  deep  abscess  as  well.  The  cause  of  the 
condition,  however,  is  probably  alike  in  both,  the 
depraved  state  of  the  local  nutrition  of  the  part  render- 
ing its  breakdown  easy  under  slight  irritation  or  pres- 
sure. Bed-sores  are  of  bad  significance  generally,  on 
account  of  this  low  condition  of  the  system  which  they 
indicate,  but  they  are  not  invariably  signs  of  hopeless 
deterioration  or  rapid  failure  from  exhaustion. 

Other  trophic  alterations  that  are  met  with  in 
advanced  cases  are  blue  edema  of  the  lower  limbs  and 
asphyxias  of  the  extremities ;  the  former  is  not  uncom- 
mon in  old  demented  cases,  and  in  those  in  which  there 
is  organic  disease  of  the  nervous  centers.  The  limb 
becomes  swollen,  pits  readily  on  pressure,  is  of  a  dull 
lead  color,  or  deadly  bluish,  and  the  swelling  usually  is 


TROPHIC    CHANGES.  69 

confined  to  the  part  below  the  knee.  It  is  probable 
that  in  many  of  these  cases  kidney  disorder  also 
exists,  but  in  some  cases  no  albuminuria  can  be 
detected.  Local  asphyxias  or  vasomotor  spasms  of 
the  part  more  or  less  affected  are  also  not  infrequent, 
and  may  be  permanent,  especially  in  the  lower  limb 
in  some  old  cases  of  chronic  dementia,  more  especially 
those  with  depression.  The  circulation  of  the  lower 
limbs  is  very  commonly  poor,  and  this  may  go  so  far 
as  to  produce  local  gangrene. 

A  striking  trophic  change  in  the  insane  is  the  fra- 
gility of  the  bones  sometimes  observed,  especially  the 
ribs,  which  break  under  very  inadequate  provocation. 
Campbell  *  found  that  while  the  normal  breaking 
strains  of  ribs  is  from  62  to  65  pounds,  in  paretics  it 
averages  only  about  44  pounds,  and  in  female  senile 
dements  it  may  be  as  low  as  11  or  12  pounds.  In 
paresis  the  other  long  bones  may  be  similarly  fragile, 
and  probably  from  the  same  pathologic  conditions  that 
have  produced  the  like  condition  in  some  tabetics. 
In  old  dements,  where  this  symptom  is  also  common, 
it  is  probably  due,  as  Meyer  f  suggests,  to  a  vice  of 
nutrition  causing  deficiency  of  lime  salts  or  some  other 
important  element  in  the  bones. 

Another  prominent  vasomotor  symptom  also  noted 
in  depressed  conditions  is  the  so-called  dermography, 
in  which  a  line  drawn  on  the  skin  remains  for  some 
little  time  visible  as  a  red  mark,  or  as  a  white  pale  mark 
bordered  with  red.  It  is  possible  sometimes  to  write 
whole  sentences  before  they  fade  out  completely. 
This  is  an  exaggeration  of  a  symptom  which  is  much 
more  commonly  met  with,  even  in  the  sane  under 
certain  conditions  of  temperature  and  exposure,  than 
is  generally  supposed  to  be  the  case. 

The  cause  of  the  dermography  is  a  local  paralysis 
and  spasm  combined,  as  is  shown  by  the  pale  line  in 

*"Jour.  Merit.  Sci.,"  April,  1895.         t"Arch.  f-  Psych.,"  xxix. 


yo  GENERAL    SYMPTOMATOLOGY. 

the  center  bordered  with  red.  In  less  complete  cases 
only  the  red  mark  appears. 

The  pulse  in  insanity  has  been  much  studied.  It  is 
decreased  in  frequency  in  many  forms  of  melancholia 
and  in  old  cases  of  chronic  depressive  insanity;  it  is 
also  decreased  in  frequency  in  certain  forms  of  organic 
dementia.  In  many  of  these  cases  its  tension  is  high. 
This  is  especially  so  in  the  more  profound  melancholiacs. 
A  low-tension  pulse  in  this  condition  is  said  to  have 
a  worse  prognosis  than  the  opposite.  In  stuporous 
insanity  it  is  also  apt  to  be  slow,  with  generally  a  lower 
tension,  but  this  is  not  always  the  case.  In  fact,  a 
high-tension  pulse  is  rather  common  in  these  cases. 
In  acute  mania  there  is  apt  to  be  a  quick,  active  pulse, 
due  to  the  general  excitement  attendant  on  the  con- 
dition, and  in  acute  delirious  mania  it  is  exceedingly 
rapid  and  febrile  in  its  character.  The  pulse  in 
general  paralysis  has  been  very  much  studied,  and  a 
rather  typical  series  of  sphygmograms  have  been  de- 
scribed. In  the  early  stages  the  arterial  tension  is 
likely  to  be  low,  increasing  in  the  second  stage,  and 
sometimes  continuing  thus  even  to  its  latest  period. 
The  pulse  in  epilepsy  varies  very  much  according  to 
the  numerous  conditions  which  may  exist.  There  is 
apt  to  be  a  more  or  less  hypertrophied  heart,  which 
will  show  itself  in  the  pulse  tracings. 

As  a  rule,  it  may  be  stated  that  a  high-tension  pulse, 
though  common  in  some  curable  conditions,  is  not  so 
favorable  a  symptom  in  insanity  as  is  the  opposite, 
since  it  indicates  a  loss  of  arterial  elasticity,  which,  if 
permanent,  is  not  a  favorable  symptom  as  regards 
recovery  from  the  disease.  The  blood-pressure  has 
been  held  to  be  of  much  significance  in  depressed  in- 
sanity and  its  reduction  an  important  therapeutic 
indication. 

The  temperature  in  insanity  varies ;  while,  as  a  rule, 
mental  disorders   are  considered  to  be  afebrile,   yet 


TROPHIC    CHANGES.  7 1 

there  are  many  cases  in  which  a  more  or  less  marked 
elevation  of  temperature  occurs.  In  acute  delirium 
especially  is  this  true.  The  temperature  may  rise  to 
a  very  great  height,  and  it  is  usually  decidedly  pyretic. 
In  general  paralysis,  also,  there  is  a  rise  in  temperature 
which  is  more  marked  in  the  evening,  and  is  aggravated 
after  the  epileptiform  and  apoplectiform  attacks  to 
which  paretics  are  liable.  In  ordinary  acute  mania 
the  temperature  sometimes  rises  with  the  excitement 
a  degree  or  two  above  the  normal,  and  in  ordinary 
forms  of  acute  melancholia  the  reverse  is  true.  We 
may  say  that,  as  a  rule,  the  temperature  of  the  acutely 
insane  is  higher  than  that  of  the  normal  individual, 
though  the  difference  is  not  very  pronounced.  Natur- 
ally, in  cases  with  serious  bodily  complications,  such 
as  the  insanity  attending  certain  chronic  diseases  like 
tuberculosis,  the  temperature  will  follow  the  rule  of 
the  disease  to  a  greater  or  less  extent.  The  use  of  the 
thermometer  is  especially  important  in  insanity,  as  by 
it  diseased  conditions  can  frequently  be  detected  when 
the  rational  signs  have  been  more  or  less  obscured  by 
the  mental  condition  of  the  subject.  Insane  patients 
frequently  go  through  very  serious  diseased  conditions 
without  showing  the  ordinary  symptoms.  They  may 
be  suffering  from  pneumonia,  without  cough,  sputum, 
or  apparent  disability,  and  even  the  physical  signs  may 
be  at  times  somewhat  obscured  or  apparently  absent. 
On  the  other  hand,  diseases  which  ordinarily  pursue 
an  actively  febrile  course  occur,  in  mental  diseases, 
without  such  symptoms,  and  both  these  facts  must  be 
kept  in  mind  when  treating  these  disorders  in  the  in- 
sane. In  epilepsy  the  temperature  sometimes  takes 
very  decided  oscillations  in  connection  with  the  attack, 
and  epileptics  are  especially  liable  to  aberrant  tem- 
perature under  other  conditions,  possibly  owing  to  a 
hysteric  element  that  very  commonly  exists  in  this 
disorder. 


72  GENERAL    SYMPTOMATOLOGY. 

Subnormal  temperature  is  met  with  in  extreme 
depressed  conditions,  and  also  in  certain  stages  of 
acutely  agitated  insanity,  especially  those  which  expose 
themselves  to  the  cold,  and  thus  reduce  the  bodily 
temperature.  It  has  been  reported  as  low  as  88°,  or 
even  lower  in  some  cases,  and  it  is  probable  that  these 
are  more  common  than  has  been  recorded.  A  very 
low  temperature  is  naturally  a  bad  symptom,  but  in 
many  of  these  cases  it  must  occur  in  patients  afterward 
making  a  good  physical  recovery. 

The  normal  slight  evening  rise  of  temperature  may 
be  absent  or  it  may  be  lower  than  that  of  the  morning, 
thus  reversing  the  normal  conditions.  Holm  *  has 
found  this  typus  inversus  occurring  in  30%  to  35%  of 
the  insane  examined  by  him,  and  considers  it  an  im- 
portant temperature  characteristic  of  insanity  that 
may  have  some  diagnostic  importance. 

Local  variations  of  bodily  temperature  are  not  infre- 
quent in  the  insane,  and  are  especially  marked  in  some 
hysteric  cases,  and  sometimes  in  epileptics. 

The  sensory  symptoms  of  insanity  are  manifold. 
The  general  sensibility  may  be  exalted,  as  in  some 
forms  of  acute  excitement,  and  there  are  occasionally 
observed  signs  of  hyperalgesia,  neuralgias,  etc.  The 
connection  between  these  and  the  mental  disorder  is 
sometimes  striking.  We  have  seen  a  ferocious  tri- 
geminal neuralgia  alternate  with  mania,  being  entirely 
absent  during  the  mental  derangement.  Angina  pec- 
toris is  sometimes  an  alternative  to  epileptic  mania 
and  convulsions.  A  peculiar  neuralgic  symptom  is 
characteristic  of  melancholia;  it  is  the  so-called  pre- 
cordial anguish,  and  is  probably  a  neurosis  of  the  vagus, 
possibly  a  central  irritation  causing  bronchial  spasm 
and  cardiac  distress.!     It  is  present  in  some  stages  in 

*  "Norsk.  Mag.  p.  Laegervidensk,"  Jan.,  1900. 
f  Ziertmann,   "Munch,   med.  Wochenschr.,"  1894,  Nos.   38  and 
39- 


MOTOR    SYMPTOMS.  73 

a  very  large  proportion  of  melancholiacs.  Anesthesia 
or  analgesia  to  temperature  and  pain  is  still  more 
frequent ;  insane  patients  endure  exposure  to  cold  and 
severe  burns  apparently  without  showing  the  least 
discomfort,  and  they  may  wound  or  seriously  mutilate 
themselves  and  seemingly  take  pleasure  in  so  doing. 

Motor  Symptoms. — Motor  excitation  has  been  al- 
ready referred  to  in  connection  with  the  mental  symp- 
toms, but  an  additional  word  or  two  will  not  be  amiss. 
In  extreme  cases  of  mania  the  patient  is  in  almost 
constant  action,  and  seems  unable  to  sit  still  for  a 
moment,  and  this  continues  until  sometimes  the 
patient  is  carried  off  by  absolute  physical  exhaustion. 
Other  motor  symptoms,  more  special  in  their  character, 
that  are  frequently  noticed  in  insanity  are,  besides 
epilepsy  and  epileptiform  convulsions,  which  are  com- 
mon in  many  organic  cases,  the  grinding  of  the  teeth, 
which  is  a  characteristic  symptom  in  some  of  the  ad- 
vanced stages  of  paresis ;  the  contractures,  which  some- 
times are  voluntary  in  the  beginning,  but  become  per- 
manent later  in  certain  stages  of  dementia.  Neglected 
patients  will  sometimes  place  their  limbs  in  positions 
and  maintain  them  there  until  it  seems  almost  impos- 
sible to  reduce  them  to  their  former  flexibility.  Some- 
times they  will  close  their  fists  in  such  a  way  as  to 
make  the  nails  go  into  the  palms,  and  create  a  very 
offensive  condition  from  the  retained  perspiration. 
Actual  contractures  are  met  with,  of  course,  in  organic 
cases,  and  hysteric  contractures  are  not  uncommon. 
Tremor  is  a  characteristic  symptom  of  paresis,  and  one 
of  the  earliest.  It  also  occurs  in  states  of  weakness  in 
many  other  forms  of  insanity.  A  very  peculiar  form  of 
motor  disturbance  that  has  given  a  name  to  a  so-called 
species  of  mental  disease  is  general  muscular  rigidity, 
the  so-called  catalepsy.  In  typical  cases  the  limbs 
and  body  retain  the  position  in  which  they  are  placed 
for  an  indefinite  period  or  until  gravitation  has  brought 


74  GENERAL    SYMPTOMATOLOGY. 

about  a  change.  The  body  is  sometimes  like  a  jointed 
lay  figure,  easily  placed  in  any  position,  which  it 
retains.  This  is  what  has  been  called  waxy  flexibility. 
This  muscular  tension  varies  in  degree;  in  some  cases 
it  only  produces  a  certain  awkwardness  of  movement, 
that  is  especially  noticeable  in  certain  stages  of  this 
so-called  catatonia,  but  never  reaches  the  full  degree 
described  above.  The  patient  has  a  tendency  to  retain 
his  arms  or  limbs  in  certain  positions,  but  overcomes 
it.  Such  cases,  however,  are  not  very  frequent.  My- 
oidema,  a  localized  temporary  spasm,  produced  by  tap- 
ping a  muscle,  and  causing  a  slight  local  swelling  by 
contraction  of  the  fibers  underneath,  lasting  for  a 
moment  or  more,  has  been  observed.  Bernstein  found 
this  symptom  frequent  in  general  paresis  and  adolescent 
insanity,  but  absent  in  the  acute  confusional  types 
and  some  other  forms.  It  is  probably  a  symptom  of 
morbid  innervation  affecting  the  muscles,  connected 
with  central  abnormalities,  and  may  be  related  to  the 
more  general  motor  irritability  that  produces  the 
symptoms  of  catatonia. 

Paralytic  disorders  are,  of  course,  often  observed  in 
organic  insanity  due  to  disease  of  the  brain,  and  in  the 
course  of  paresis,  which  is  characterized  especially  in 
its  later  stages  by  an  advancing  weakness  of  the 
muscular  system.  Hypochondriacal  paralysis  is  also 
another  form,  which,  however,  belongs  more  to  the 
mental  symptoms  than  the  physical.  Hysteric  paraly- 
sis is  also  frequent  in  insanity  where  the  hysteric 
element  is  a  prominent  feature,  and  is  sometimes 
difficult  to  distinguish  from  actual  organic  trouble.  In 
hypochondriacal  paralysis  the  diagnosis  is  easier,  from 
the  fact  that  there  is  no  atrophy  and  that  sudden  ex- 
citation may  sometimes  bring  about  complete  restora- 
tion of  the  function.  In  hysteria  this  is  not  so  entirely 
true,  and  there  may  be  atrophy  in  time,  though  its  ab- 
sence is  usually  characteristic. 


MOTOR    SYMPTOMS.  75 

Mention  has  been  already  made  in  a  previous  chapter 
of  the  physical  stigmata  of  mental  disease.  A  re- 
capitulation of  some  of  them,  however,  is  appropriate 
in  this  place.  Deformities  of  the  cranium  include  all 
the  various  misshapen  conditions  that  are  known  under 
the  names  of  microcephaly,  macrocephaly,  scapho- 
cephaly, plagiocephaly,  platicephaly,  acrocephaly,  etc. 
In  these  the  head  is  either  too  large  or  very  notably 
small.  It  may  be  unequal  in  its  size  on  the  two  sides, 
flat  or  steeple-shaped  on  top,  etc.  Inasmuch  as  no  head 
is  perfectly  symmetric,  these  conditions  have  to  be 
decidedly  pronounced  to  be  of  importance  as  symptoms 
of  mental  deficiency.  In  the  face  we  have  various 
irregularities:  asymmetry;  deformities  of  the  eyes, 
nose,  mouth,  and  especially  of  the  jaws,  which  may  be 
projecting,  and  the  upper  jaw  excessively  arched  or 
flat ;  the  teeth  may  be  deficient  or  excessive  in  develop- 
ment, as  well  as  irregular.  There  may  be  palatal 
deficiencies,  traces  of  branchial  clefts  in  the  neck  or  side. 
Special  importance  has  been  attributed  to  the  shape 
of  the  ear,  but  all  its  deformities  may  exist  in  the 
mentally  sound  as  well  as  in  the  insane ;  only  in  connec- 
tion with  other  symptoms  are  its  abnormalities  of  value. 
In  the  thorax  we  may  have  deformities  known  as  flat 
chest,  pigeon-breast,  etc.,  and,  what  is  probably  more  a 
degenerative  sign  than  any  of  them,  the  funnel-shaped 
thorax.  Deformities  of  the  genital  organs  are  espe- 
cially important,  and  should  be  noted.  Also  any 
general  defects,  such  as  bodily  asymmetry,  either  of 
the  whole  body  or  of  special  members ;  deformities  such 
as  club-foot,  flat-foot,  supernumerary  toes  or  digits; 
— all  these  have  more  or  less  importance  as  indications 
of  defective  development,  and  consequently  have  a 
connection  with  mental  disorders  when  they  exist. 
The  condition  of  the  skin  is  also  to  be  noted ;  its  mois- 
ture or  dryness,  and  any  precocious  wrinkles  in  the 
face   which   would    seem   to   be    signs    of   premature 


76  GENERAL    SYMPTOMATOLOGY. 

senility.  The  growth  of  hair  is  also  of  some  significance. 
A  beardless  man  or  a  bearded  woman  are  both  of  them 
abnormal.  An  unusual  growth  of  hair  is  not  uncom- 
mon in  insane  females,  especially  about  the  face.  The 
general  physiognomy  of  the  insane  is  made  up  of  a 
vast  number  of  these  peculiarities,  but  it  is  less  charac- 
teristic in  some  respects  than  is  generally  believed  by 
the  public.  In  pronounced  insanity,  of  course,  there 
is  no  difficulty  in  recognizing  the  disturbance,  and  the 
difference  in  appearance  of  the  same  individual  during 
the  disorder  and  after  recovery  is  sometimes  most 
remarkable.  Patients  seen  at  their  worst  are  often 
almost  or  quite  unrecognizable  after  their  insanity  has 
left  them.  It  is  especially  disfiguring  in  the  case  of 
females.  In  certain  forms  of  chronic  insanity,  and  in 
epilepsy  and  paretic  dementia  in  its  later  stages,  there 
is  often  a  characteristic  physiognomy  which  can  hardly 
be  mistaken  by  any  one  accustomed  to  observing  these 
cases. 


CHAPTER  VI. 

COURSE  AND  TERMINATIONS. 

The  beginnings  of  insanity  are  often  insidious ; 
especially  is  this  the  case  with  forms  that  take  from 
the  start  a  chronic  course.  The  prodromata  are 
very  commonly  overlooked  in  acute  cases,  and  it 
often  happens  that  only  a  retrospective  study  of  the 
history  of  the  case  very  carefully  made  will  give  any 
idea  of  the  conditions  that  preceded  the  attack.  We 
may  say,  in  a  general  way,  that  the  beginnings  of 
insanity  vary,  and  divide  into  two  great  classes  of 
cases — those  in  which  there  is  a  pronounced  neuro- 
pathic or  psychopathic  predisposition,  and  those  in 
which  the  mental  disease  occurs  in  a  normally  or 
nearly  normally  constituted  individual.  In  the  first 
class  the  outbreak  may  be  extremely  sudden  and  have 
but  little  in  the  way  of  antecedents.  The  patient  may 
be  apparently  in  perfect  health  and  without  anything 
in  his  or  her  symptoms  that  leads  to  any  anticipation 
of  the  outbreak.  Generally,  however,  there  are  a  few 
prodromata — some  change  in  disposition,  an  unusual 
irritability  or  excitability,  or  some  slight  changes  in 
manner  or  disposition  that  are  remembered  by  the 
closest  friends  after  the  onset  of  the  disorder.  There 
are  frequently,  also,  disturbance  of  sleep,  sometimes 
amounting  to  decided  insomnia,  and  a  constipated 
condition  of  the  bowels,  with  more  or  less  digestive 
disorder.  Patients  who  have  suffered  from  acute 
attacks,  and  especially  more  than  one,  coming  on  sud- 
denly while  engaged  in  their  ordinary  occupations, 
have  stated  that  if  they  could  avoid  constipation  and 
sleeplessness,  they  could  also  avoid  the  attacks.     Of 

77 


78  COURSE    AND    TERMINATIONS. 

course,  it  generally  happens  that  the  causes  of  these 
conditions  of  which  they  complain  lie  still  further 
back,  and  are  ignored  by  them. 

In  cases  where  there  is  no  hereditary  or  other  pre- 
disposition to  insanity,  and  where  it  occurs  from 
known  or  suspected  etiologic  conditions  of  illness,  over- 
work, mental  trouble,  etc.,  there  is  very  commonly  a 
preliminary  period,  where,  besides  the  disorders  of 
digestion  and  sleep,  there  is  a  more  or  less  marked 
depression,  some  weakness  of  memory,  and  other  in- 
tellectual disturbance  that  may  excite  the  attention 
of  those  about  them,  and  lasting  for  some  days  before 
the  outbreak  of  actual  acute  insanity.  This,  in  fact, 
is  so  common  that  it  has  been  considered  by  some 
authors  as  a  rule,  and  a  prodromal  period  of  depression 
has  been  described  as  the  usual  thing  in  cases  of  acute 
mania.  In  periodic  insanity,  which  is  usually  a 
degenerative  psychosis,  the  suddenness  of  the  changes 
and  of  the  onset  of  the  attack  is  very  marked,  and  the 
causal  factors,  immediate  or  otherwise,  may  be  so 
slight  as  to  be  absolutely  undetectable.  The  patient 
may  break  down  at  once  into  a  state  of  acute  melan- 
cholia, but  more  commonly  there  is  an  exalted  condi- 
tion of  intellectual  excitement,  which  may,  in  many 
cases,  not  exceed  the  normal  condition  of  the  individual 
to  such  an  extent  as  to  make  those  about  him  consider 
him  actually  insane.  Many  of  these  people  have  during 
the  greater  period  of  their  lives  been  considered  as  simply 
eccentrics,  subject  to  spells  of  uncommon  vivacity  of 
mind,  alternating  with  those  of  depression. 

In  the  more  chronic  forms  of  insanity  the  onset  is 
more  insidious,  as  already  stated.  The  patient  for  a 
long  time  develops  peculiarities  which  are  at  first  un- 
noticed, but  gradually  begin  to  be  remarked,  and  are 
particularly  remembered  when,  by  some  act,  the  full- 
fledged  mental  disorder  reveals  itself.  In  a  case  of  para- 
noia it  may  be  months  or  years  before  the  individual 


course.  79 

is  even  suspected  of  being  in  any  way  wrong.  There  is 
a  sort  of  conflict  that  sometimes  exists  between  his 
correct  judgment  and  his  disease,  and  yet  he  is  able  to 
conceal  his  mental  disorder  to  such  an  extent  that  he 
can  go  about  his  daily  occupation  unsuspected.  Sooner 
or  later,  however,  actions  and  words  betray  his  condition, 
though  in  these  cases  it  often  happens  that  it  is  difficult 
to  convince  friends  and  relatives  that  there  is  anything 
wrong.  Patients  of  this  class  have  mingled  with  their 
fellows  for  years,  always  sources  of  danger,  but  with  their 
condition  suspected  or  recognized  by  but  few.  In  pro- 
found organic  dementia  and  in  paresis  there  is  generally 
sufficient  change  of  habits  and  morals  to  make  the  con- 
dition recognizable  or  suspected,  at  least  before  it  has 
progressed  very  far.  What  difficulties  there  are  in  this 
regard  will  be  noticed  more  at  length  in  the  chapter  on 
diagnosis.  In  certain  cases  the  attack  of  insanity  may 
be  so  transitory  that  its  whole  duration  covers  only  a 
few  hours  or  days.  Transitory  frenzy,  though  denied  by 
some  authors,  is  a  recognizable  and  well-established 
form  of  mental  disease.  The  pre-  and  post-epileptic 
conditions  are,  of  course,  so  generally  associated  with 
the  marked  symptoms  of  the  neurosis  as  not  to  require 
further  remarks  here  in  this  regard. 

The  course  of  insanity,  when  it  is  once  fairly  estab- 
lished, may  be  continuous  or  intermittent.  In  acute 
cases,  especially  of  mania,  it  is  apt  to  be  short,  though 
relapses  may  occur.  In  certain  forms  of  exhaustional 
and  toxic  insanity  it  is  almost  self-evident  by  the 
physical  condition  of  the  patient.  Melancholia  and 
depressed  and  stuporous  conditions  generally  are  apt 
to  drag  along  over  a  greater  length  of  time,  and  the 
changes  that  occur,  excepting  in  the  periodic  cases, 
are  apt  to  be  more  gradual. 

It  is  customary,  or  has  been  so,  in  many  asylums  to 
consider  a  case  that  has  continued  without  pronounced 
steps  towards  convalescence  for  a  year  or  more   as 


80  COURSE    AND    TERMINATIONS. 

chronic,  but  this  is  no  absolute  criterion.  In  the  most 
acute  forms  of  mania  there  is  apt  to  be  so  much  damage 
done  to  the  brain  after  a  certain  period  that  this 
tendency  to  chronicity  thus  recognized  has  some  basis 
of  reality.  Nevertheless,  cases  have  been  noted  of 
acute  mania  lasting  for  much  longer  periods  than  one 
year,  without  apparent  amelioration,  and  ending  in  a 
condition  which  might  at  least  be  considered  as  an 
approximate  recovery.  In  melancholia  there  is  no 
limit  to  the  time  when  recovery  may  take  place,  though 
relapses  are  liable  to  occur  in  any  form  of  acute  in- 
sanity; and  this  should  be  especially  held  in  mind, 
since  the  majority  of  cases,  at  least,  of  acute  mania 
are  based  on  a  degenerate  constitution,  and  may  per- 
haps be  considered,  with  Kraepelin,  as  forms  or  phases 
of  periodic  insanity.  The  lucid  periods,  however,  in 
some  of  them  are  so  long  that,  practically  speaking, 
we  may  consider  them  as  recovered.  It  is  hardly  fair 
to  reckon  a  lucid  interval  of  years  in  duration  as  any- 
thing else  than  at  least  a  temporary  recovery. 

Remissions  may  occur  in  many  forms  of  mental 
disease,  and  sometimes  these  may  last  for  considerable 
periods,  even  in  organic  disease,  like  paresis.  They 
are,  in  fact,  common  in  this  condition,  and  sometimes 
last  so  long  as  to  lead  to  a  suspicion  of  recovery,  though 
this  is  generally  disappointed  sooner  or  later  by  a 
relapse  to  the  former,  or  a  worse,  condition.  In  acute 
mania  there  are  often  short  intervals  in  which  the 
patient  seems  almost  his  normal  self  for  a  short  period. 
Acute  melancholia,  not  of  the  periodic  type,  is  more 
continuous.  We  recognize  a  difference  between  these 
remissions  and  the  periodic  changes  of  cyclic  insanity 
which  occur  with  more  or  less  regularity,  while  the 
others  are  altogether  irregular  in  their  occurrence  and 
duration.  It  is  not  rare  to  see  an  intercurrent  affection 
—some  serious  bodily  disease,  for  example — produce 
a  very  decided  remission  of  the  symptoms,  and  some- 


TERMINATIONS.  8 1 

times  a  complete  temporary  restoration  of  the  mental 
function.  This  is  even  observed  in  old  chronic  cases, 
though  it  is  rare  in  such.  The  same  phenomenon  has 
been  observed  in  the  very  low  conditions  that  precede 
death.  Sometimes  moribund  patients  that  may  have 
appeared  demented  for  months  or  years  may,  in 
articulo  mortis,  show  surprising  signs  of  mental  clearness, 
though  under  the  circumstances,  it  must  be  remem- 
bered, such  symptoms  impress  themselves  unduly  upon 
observers  and  are  easily  exaggerated. 

There  may  also  be  a  change  in  the  type  of  insanity, 
accompanied  with  decided  mental  improvement.  A 
silly,  demented  patient  has  been  known  to  become 
suddenly  dangerous  and  violent,  while,  at  the  same 
time,  his  mental  functions  seemed  greatly  improved. 
Instead  of  being  absolutely  irrational,  he  was  logical 
and  consecutive  in  his  talk,  and  appeared  more  as  a 
surly,  dangerous  case  than  a  demented  one. 

The  duration  of  insanity  is  naturally  variable,  but 
it  may  be  said  that  there  is  no  limit  to  it  except  that 
of  life.  This  is  true  in  the  chronic  cases,  many  of  whom 
live  out  a  long  life  in  a  state  of  mental  hebetude  or 
dementia,  and  it  is  also  the  case  in  certain  forms  of 
delusional  insanity.  Cases  that  recover  generally  do 
so  during  the  first  year  or  eighteen  months,  but  cases 
of  recovery  after  many  years  have  been  often  recorded. 

Terminations. — The  terminations  of  insanity  may  be 
classed  as  follows:  First,  recovery;  second,  recovery 
with  defect,  partial  recovery,  or  improvement;  third, 
passage  into  the  chronic  condition ;  fourth,  death. 

Recovery. — Recovery  occurs  in  a  certain  proportion  of 
cases,  which  has  usually  been  estimated  to  be  as  high 
as  30%  or  35  %.  It  must  be  remembered,  however,  that 
the  estimation  of  recovery  largely  depends  on  the  point 
of  view  and  the  personal  equation  of  the  person  making 
the  estimate.  In  former  times  some  asylum  super- 
intendents reported  as  high  as  75,  80,  90,  or  100%  of 
6 


82  COURSE    AND    TERMINATIONS. 

recoveries  on  admissions.  At  the  present  time  the 
tendency  is  rather  the  other  way  amongst  alienists, 
and  they  are  cautious  in  reporting  recoveries,  so  that 
the  actual  percentage  is  being  reduced  in  many  tables 
to  a  still  lower  figure  than  the  one  first  mentioned. 
The  forms  of  insanity  that  may  end  in  recovery,  and 
in  which  we  may  even  say  it  is  to  be  expected,  under 
favorable  conditions,  are  the  acute,  toxic,  and  ex- 
haustional  conditions  and  the  post-febrile  insanities. 
Simple  melancholia  of  the  milder  type,  and  mania,  are 
also  usually  reckoned  as  hopeful  forms  of  insanity. 
The  fact,  however,  that  simple  mania,  as  Kraepelin 
has  pointed  out,  is  generally  a  degenerative  psychosis, 
and  that  relapses  or  recurrences  are  almost  inevitable, 
modifies  the  prognosis  somewhat  in  these  cases,  and 
makes  it  a  question  whether  we  should  consider  them 
to  be  generally  amongst  the  recoverable  forms.  The 
same  is  true,  also,  to  some  extent,  of  melancholia  when 
it  is  not  a  disease  of  evolution  or  connected  with  the 
retrogressive  changes  of  life.  Many  cases  of  melan- 
cholia, however,  occur  outside  of  institutions  that  are 
never  recorded  or  properly  observed,  and  it  is  difficult 
to  get  statistics  as  to  the  recurrence  of  the  disorder  in 
such  cases.  As  regards  mania,  distinguishing  it 
clearly  from  confusional  and  other  forms  that  are 
sometimes  included  under  this  head,  the  case  is  some- 
what different.  In  an  analysis  of  65  cases,  Van  Erp 
Tallman  Kip  found  that  there  were  only  4  in  which  it 
could  be  certainly  said  there  had  occurred  only  a  single 
attack  of  mania,  and  he  concludes  that  the  tendency 
to  recurrence  should  be  considered  the  most  important 
clinical  feature  of  this  special  type  of  insanity.  As 
already  stated,  however,  it  is  hardly  fair  to  consider  in- 
sanity as  continuing  over  a  perfect  intermission  that 
may  last  for  ten  or  fifteen  years,  or  more,  as  happens 
in  some  of  these  cases.  An  attack  of  mania  lasting 
only  a  few  weeks  might  be  considered  as  a  recover- 


TERMINATIONS.  83 

able  form  of  insanity,  when  it  does  not  recur  within 
a  reasonable  period  of  years. 

Recoverv  usually  takes  place  gradually.  There  are 
short  remissions  or  intermissions ;  the  patient  gradually 
quiets  down  from  his  excitement,  takes  more  natural 
and  rational  views  of  his  surroundings,  and  finally  is 
apparently  restored  to  his  normal  self.  During  this 
period,  however,  there  may  be  days  in  which  the  recur- 
rence of  the  old  symptoms,  to  a  greater  or  less  extent, 
is  manifested,  and  it  sometimes  happens  that  an 
apparentlv  complete  recovery  is  followed  by  a  quick 
relapse  for  a  shorter  or  longer  period.  In  some  cases 
recovery  is  rapid ;  the  patient  comes  almost  instantane- 
ously out  of  his  frenzied  condition,  and  is  rational  and 
quiet.  In  some  cases,  also,  the  relief  of  symptoms  of 
insomnia  and  of  constipation  produces  a  very  rapid 
and,  as  it  were,  instantaneous  cure.  The  writer  has 
seen  a  case  which  for  months  had  been  suicidal,  de- 
pressed, and  inactive,  requiring  artificial  alimentation, 
and  close  attention  in  every  way,  apparently  make  a 
rapid  recovery  after  a  free  injection  which  relieved  an 
overloaded  bowel.  From  being  bed-ridden,  almost  help- 
less, acutely  depressed  and  suicidal,  and  apparently 
without  strength  enough  to  attend  to  his  natural 
wants,  he  immediately  after  the  relief  got  up  and 
dressed  himself,  made  his  escape  in  spite  of  long  search, 
and  the  next  thing  was  a  perfectly  rational  letter  received 
from  him  stating  that  he  was  well  and  asking  that  his 
clothes  be  sent  home.  The  recovery  was  apparently 
complete,  and,  as  far  as  observed,  permanent.  It  is  not 
uncommon  in  asylums  to  have  cases  brought  there  in  a 
wildly  maniacal  condition  who,  after  a  warm  bath  and  a 
good  night's  sleep  secured  by  medication,  together  with 
relief  of  the  constipation  existing,  have  made  an  almost 
immediate  recovery,  which  certainly  persisted  for  a 
considerable  length  of  time. 

When  recovery  is  sudden,  without  any  special  cause, 


84  COURSE    AND    TERMINATIONS. 

there  is  a  suspicion,  at  least,  of  a  degenerative  predis- 
position, and  the  liability  of  recurrence  must  be  kept 
in  mind.  In  cases  attended  with  severe  bodily  illness, 
such  as  in  the  post-febrile  cases,  recovery  sometimes 
takes  place  directly  in  accordance  with  the  physical 
improvement.  In  toxic  cases  the  relief  of  the  system 
from  the  toxic  product  is  also  sometimes  attended  with 
rapid  recovery,  and  this  is  true,  not  only  in  such  forms 
as  the  delirium  from  intoxicants  like  alcohol  and  other 
drugs,  but  also  with  the  slower  forms  of  mental  disorder 
which  persist  after  the  system  has  apparently  recovered 
from  the  immediate  effects  of  the  poison.  In  other 
cases,  however,  and  perhaps  these  are  the  majority, 
the  improvement  is  slow,  the  damage  to  the  nervous 
system  being  such  as  to  prevent  or  render  difficult  its 
repair  and  full  restoration  of  function. 

We  can  say  a  patient  has  completely  recovered  when 
he  shows  absolutely  no  change  from  his  normal  self 
after  the  subsidence  of  the  attack.  Such  patients,  as  a 
rule,  appreciate  very  fully  their  condition,  and  are  grate- 
ful for  the  care  and  control  that  they  have  received. 
This  gratitude,  however,  is  not  an  especially  important 
indication  of  recovery,  as  it  may  occur  equally  marked 
in  the  intermissions  of  periodic  insanity,  or  in  cases 
where  there  is  a  very  pronounced  mental  defect  re- 
maining. In  fact,  the  patients  in  a  larger  proportion 
than  is  generally  supposed  have  more  or  less  conscious- 
ness of  their  condition,  even  during  the  acme  of  the 
attack  of  insanity.  As  was  remarked,  also,  in  speaking 
of  delusions,  there  may  remain  perverted  recollections 
of  events  that  happened  during  their  disorder,  together 
with  a  generally  complete  restoration  to  mental  health. 

It  must  be  remembered,  also,  that  in  certain  forms 
of  insanity,  notably  in  the  paranoiac,  and  in  melan- 
choliac  sometimes,  there  may  be  a  wilful  suppression 
of  the  symptoms,  with  the  idea  of  creating  the  impres- 
sion that  recovery  has  taken  place. 


TERMINATIONS.  85 

Partial  Recovery  with  Defect. — It  may  be  a  ques- 
tion whether  an  acute  attack  of  mental  disorder  does 
not  invariably  leave  some  traces  on  the  organization, 
but  these  are  sometimes  so  slight  that  they  may  be 
practically  neglected.  In  a  very  large  proportion  of 
cases,  however,  recovery  is  only  partial;  the  patient, 
while  well  enough  to  be  discharged  from  care,  is 
recognized  by  friends  and  every  one  who  observes  as 
not  being  exactly  the  same  individual  as  before,  and 
this  defect  may  range  from  a  mild  general  dementia 
up  to  merely  a  slight  trace  of  mental  abnormality. 
The  question  often  arises  in  hospitals  for  the  insane, 
whether  a  patient  is  to  be  considered  as  a  case  of 
chronic  secondary  dementia,  and  retained,  or  dis- 
charged as  fit  to  take  his  part,  under  favorable  condi- 
tions, in  the  general  population.  Hence  we  have  a 
large  list  of  cases  in  their  published  tables  that  are 
described  "much  improved,"  or  "improved."  These 
are  patients  who  are  supposed  to  no  longer  require 
hospital  attention,  but  who  are  not  considered  as  fully 
recovered.  Sometimes  the  improvement  continues 
after  they  are  discharged  until  they  are  very  little 
below  their  normal  condition  mentally.  More  often, 
however,  they  continue  to  show  more  or  less  traces  of 
their  disorder,  and  it  is  very  important  in  such  cases 
that  the  home  conditions  and  surroundings  should  be 
such  as  not  to  aggravate  their  mental  irritability,  or  to 
claim  too  much  in  the  way  of  work  or  responsibility. 
They  are  still,  to  some  extent,  weaklings,  and  should 
be  considered  as  such. 

Passage  to  the  Chronic  Condition. — The  difference 
between  this  termination  and  that  of  the  last  described 
form  of  acute  mental  disease  is  not  a  very  definite 
one.  In  fact,  many  of  the  cases  counted  as  par- 
tially recovered  may  also  be  considered  as  examples 
of  mild  chronic  general  mental  impairment.  In  other 
cases,  however,  the  disease  passes  over  to  the  chronic 


86  COURSE    AND    TERMINATIONS. 

condition  with  only  a  slight  abatement  of  its  symptoms. 
The  patients  are  still  wildly  disturbed,  demented,  or 
deluded.  It  is  a  bad  sign  in  a  case  of  acute  insanity 
when  marked  physical  improvement  begins  to  appear 
without  correspondent  betterment  in  the  mental  con- 
dition. A  very  large  proportion  of  asylum  inmates 
have  begun  as  acute  cases,  but  instead  of  passing  to 
recovery,  they  have  relapsed  or  fallen  into  a  chronic 
condition.  As  a  rule,  there  is  a  modification  of  their 
symptoms  from  those  of  the  acute  stage.  They  are 
less  pronounced;  the  patient  is  less  wild;  the  bodily 
functions  are  more  naturally  carried  on,  but  over  the 
whole  symptom-complex  there  is  a  peculiar  change 
that  marks  its  chronicity.  The  pronounced  element 
of  dementia  is  perhaps  the  most  common  type  of  this. 
This  varies,  of  course,  according  to  the  mental  consti- 
tution of  the  individual  and  the  nature  of  the  insanity. 
Some  are  agitated  and  maniacal;  others  depressed; 
others  decidedly  deluded,  while  others  simply  seem  to 
show  very  pronounced  mental  weakness. 

Death. — Death  is  a  frequent  termination  of  acute 
insanity.  Of  course,  it  is  the  final  termination  in 
nearly  every  case  of  chronic  mental  disease.  The  ratio 
of  mortality  in  the  best  regulated  asylums  is  hardly 
less  than  7%,  even  under  favorable  conditions,  which 
is  about  four  times  as  great  as  should  exist  in  well- 
regulated  municipalities  of  the  ordinary  population. 
If,  however,  we  take  out  certain  forms  of  insanity, 
such  as  paresis  and  organic  dementia,  we  have  the 
ratio  somewhat  reduced.  In  any  case,  however,  it  will 
decidedly  exceed  that  amongst  the  general  population. 
The  death-rate  in  asylums  is  less  than  that  of  the  insane 
outside  of  these  institutions,  excluding  the  slight  cases 
of  melancholia  and  certain  chronic  degenerative  forms 
that  are  largely  permitted  to  be  free  from  restraint. 
In  acute  insanity  death  may  occur  from  various  causes. 
In  exhaustive  conditions  the  patient  may  wear  himself 


TERMINATIONS.  87 

out,  and  die  from  overstrain  and  lack  of  proper  nutri- 
tion. In  depressed  cases  there  is  also  defective  nutri- 
tion, and  sometimes  final  exhaustion  and  death.  Very 
commonly,  however,  this  occurs  from  an  intercurrent 
affection,  such  as  pneumonia,  to  which  these  patients 
are,  from  their  habits,  specially  liable;  and  we  might 
add  to  this,  also,  other  lung  troubles,  serious  gastric 
disorders  due  to  irritating  substances  taken  into  the 
system,  acute  bowel  disorders,  which  are  very  frequent, 
and  tuberculosis.  This  latter  disease,  which  has  been 
considered  one  of  the  most  common  causes  of  the  fatal 
termination  of  insanity,  is  probably  at  the  present  time 
somewhat  less  frequent  as  such  than  was  formerly  the 
case.  The  facts,  however,  of  the  necessarily  unfavor- 
able conditions  which  surround  these  patients,  their 
confinement,  overcrowding  of  institutions,  and  thus 
increased  liability  to  infection,  make  it  still  a  very 
formidable  disease  in  asylums. 

Paresis,  or  general  paralysis  of  the  insane,  which 
is  increasing  in  frequency  in  all  civilized  countries,  is 
an  essentially  fatal  disorder,  and  generally  runs  its 
course  within  three  years  from  its  first  recognition. 
The  cause  of  death  in  this  condition  may  be  congestive 
or  epileptiform  attacks  to  which  the  patients  are 
liable,  any  intercurrent  disease,  and  very  often  the 
direct  result  of  the  brain  lesions  of  this  particular 
species  of  insanity.  The  patients  wear  out  gradually, 
die  with  bed-sores,  and  general  exhaustion.  The  same 
is  true  to  some  extent  of  some  forms  of  organic  insanity, 
especially  in  middle-aged  or  elderly  persons,  and  these 
cases  are  often  confounded  with  paresis  from  their 
symptoms.  Epileptics,  while,  as  a  rule,  they  are 
robust  patients,  are  also  liable  to  be  carried  off  by  the 
incidental  affections  of  their  disorder,  among  which 
are  status  epilepticus,  convulsions,  etc.  The  disorder 
should  be  classed,  of  course,  rather  among  the  organic 


OO  COURSE    AND    TERMINATIONS. 

than  the  neurotic  insanities,   as  regards  this  feature 
of  its  termination. 

The  accidents  to  which  the  insane  are  liable  are  also 
to  be  considered,  as  they  are  not  infrequent  even  in  the 
best-regulated  institutions.  Suicide  is  always  to  be 
watched  for  in  the  depressed  cases,  and  the  most 
dangerous  ones  in  this  regard  are  often  those  who  give 
but  little  warning  of  the  tendency.  A  large  list  of 
minor  accidents,  some  of  which  may  be  directly  or 
indirectly  fatal,  might  be  made.  They  are  common, 
and  are  not  so  often  reported  as  causes  of  death  as 
probably  they  should  be.  Death  follows  indirectly, 
often  after  a  considerable  time,  but  its  remote  cause, 
at  least,  might  be  considered  as  belonging  in  this 
category.  In  chronic  insanities,  tuberculosis  is  espe- 
cially frequent  as  a  cause  of  death,  but  when  we  re- 
member how  many  different  disorders  have  been  con- 
sidered as  being  the  basis  of  the  mental  disorder, 
and  many  of  these  also,  it  must  be  presumed,  continue 
throughout  the  course  of  the  patient's  life, — it  will  be 
seen  that  very  few  of  the  actively  insane,  whether 
acute  or  chronic,  can  be  counted  on  as  having  an 
ordinary  average  expectation  of  life.  Kidney  disease 
is  one  of  these  conditions  which  may  cause  death,  of 
which  in  late  years  much  has  been  written.  It  is  possi- 
ble that  this  is  overestimated.  It  is  also  more  than  prob- 
able that  serious  lesions  of  the  kidneys  are  much  more 
frequent  in  the  insane  than  in  those  of  sound  mind. 


CHAPTER  VII. 

GENERAL  DIAGNOSIS  AND  PROGNOSIS  OF 
MENTAL  DISEASE. 

The  diagnosis  of  mental  disease  is  a  very  important 
matter,  which  is  liable  to  come  before  the  general 
practitioner  at  any  time.  It  is  the  more  important 
inasmuch  as,  aside  from  involving  the  health  and 
physical  welfare,  to  a  very  large  extent,  of  the  patient, 
it  also  involves  his  freedom.  The  question  whether 
a  man  is  insane  or  not  has,  as  is  readily  seen,  very  many 
important  bearings  upon  his  relations  with  those  about 
him  and  the  validity  of,  or  his  responsibility  for,  his 
acts.  It  is  well,  therefore,  to  have  one's  general  ideas 
on  this  subject  well  prepared  beforehand,  and  to  be 
able  to  use  the  best  methods  in  ascertaining  the  facts. 

It  has  been  said  that  the  diagnosis  of  mental  disease 
varies  from  the  diagnosis  of  other  disorders  in  that  the 
patient's  cooperation  cannot  be  obtained.  This  is  not 
altogether  true.  With  a  very  large  number  of  insane 
patients,  a  fair  statement  of  the  object  of  the  investiga- 
tion, and  a  request  for  the  patient's  cooperation  as  a 
sick  man,  will  help  to  bring  out  important  facts.  When 
a  patient  is  dissimulating,  or,  what  is  perhaps  more 
rare,  simulating  insanity,  this  cooperation  cannot  be 
voluntarily  obtained,  but  the  resistance  to  the  inquiry 
itself  may  be  a  very  useful  hint  to  the  examining 
physician.  Really  insane  people,  as  has  been  said 
elsewhere,  often  have  a  certain  comprehension  or 
appreciation  of  their  own  condition,  and  when  treated 
as  invalids,  with  the  fullest  confidence,  will  return  this 
confidence  often  in  very  great  measure. 

In  examining  any  case  of  insanity,  the  examiner 


90  GENERAL    DIAGNOSIS    AND    PROGNOSIS. 

should  first  thoroughly  coach  himself  as  to  the  history 
of  the  patient  and  his  family,  so  far  as  this  is  possible. 
Not  merely  direct  heredity  should  be  looked  after,  but 
collateral.  Insanity  and  other  diseases  in  uncles  or 
aunts,  cousins,  or  even  distant  relatives ;  eccentricities  of 
ancestors,  and,  in  fact,  anything  in  the  family  history 
that  can  afford  a  possible  suggestion  to  be  followed  up. 
The  facts  thus  gained,  properly  weighed,  form  an  ex- 
cellent preface  to  the  examination  of  the  patient 
himself. 

In  examining  the  patient  the  previous  illnesses,  con- 
vulsions, injuries,  especially  of  the  head,  etc.,  should, 
of  course,  be  thoroughly  inquired  into.  The  physical 
examination  should  embrace,  first  of  all,  the  general 
aspect  and  manner,  which  will  often  reveal  something 
of  importance.  The  shape  of  the  head,  abnormalities 
of  the  features,  any  degenerative  stigmata  of  the  jaws, 
face,  ears,  bodily  asymmetry,  and,  if  necessary,  other 
physical  peculiarities,  such  as  can  only  be  obtained  by 
a  close  bodily  examination,  should  be  looked  after. 
In  pronounced  insanity  there  is  little  difficulty  in 
telling  from  the  general  physiognomy  of  the  patient 
that  mental  disease  exists;  mania  and  melancholia, 
stupor,  pronounced  dementia,  are  all  more  or  less 
characteristically  shown  by  the  manner  and  expression 
of  the  patient.  It  is  only  in  certain  forms  of  insanity 
where  the  emotional  and  cenesthetic  states  are  not 
markedly  involved  that  these  signs  fail.  Paranoias, 
and  a  large  number  of  conditions  that  are  on  the 
borderland,  and  are  hardly  as  yet  fully  established 
mental  disease,  fall  under  this  head.  Mild  melancholia 
may  pass  unrecognized,  unless  one  is  accustomed  to 
give  particular  attention  to  the  manifestations  in  this 
type,  and  there  are  no  very  conspicuous  manifestations 
in  the  acts  of  the  individual,  as  is  likely  to  be  the  case 
with  subacute  mania,  or  most  other  types  of  mental 
disorder.     All  the   special  peculiarities  mentioned  in 


PSYCHIC    EXAMINATION    OF    THE    PATIENT.  91 

the  chapter  on  symptomatology  should  be  looked  after 
— the  condition  of  the  digestion,  secretions,  motor 
function,  the  skin,  the  sensibility,  general  and  special, 
the  vasomotor  functions,  etc.  It  is  well  to  notice  very 
particularly  as  to  the  condition  of  the  patient's  excre- 
tions, his  reactions  to  temperature  and  to  the  weather 
generally,  the  state  of  his  reflexes,  both  deep  and 
superficial,  and,  in  fact,  as  to  every  thing  that  can  have  a 
bearing  on  the  question  of  the  existence  of  any  serious 
organic  or  functional  disease ;  since  it  is  only  in  cases 
where  the  insanity  is  not  self -apparent,  or  is  supposed 
to  be  simulated,  that  the  question  of  diagnosis  arises, 
and  all  these  facts  as  to  physical  condition,  degenera- 
tive stigmata,  etc.,  afford  a  certain  presumption  for  or 
against  the  existence  of  insanity  in  cases  where  through 
acts  or  otherwise  the  suspicion  has  arisen. 

It  is  well,  when  they  are  available,  to  use  also  the 
instruments  of  precision  of  medical  diagnosis,  the 
stethoscope,  the  thermometer,  the  sphygmograph,  etc., 
remembering,  however,  that  in  certain  cases  the  mental 
impression  produced  by  the  use  of  these  instruments  may 
have  an  effect  upon  the  patient's  mental  state,  and  that 
in  some  cases  it  may  be  unfavorable  to  the  bringing  out 
of  certain  important  facts.  On  the  other  hand,  it  may 
also  aid  to  reveal  peculiarities,  insane  suspicions,  or  de- 
lusions that  might  otherwise  escape  notice. 

It  is  advisable,  therefore,  to  employ  all  possible 
means,  bearing  in  mind,  of  course,  the  question  of 
their  mental  effect. 

Psychic  Examination  of  the  Patient. — When  organic 
disease  or  defect  is  proved  or  excluded,  special  atten- 
tion should  be  given  to  the  examination  of  the  patient's 
mental  condition.  The  peculiarities  of  physiognomy, 
etc.,  have  already  been  noticed,  but  it  may  be  said, 
in  addition,  that  every  possible  alteration  or  modifica- 
tion of  the  features  of  expression,  the  gait,  and  pecu- 
liarities of  acts  should  be  carefully  noted,  as  they  may 


92  GENERAL    DIAGNOSIS    AND    PROGNOSIS. 

give  very  valuable  indications  as  to  the  mental  con- 
dition. A  little  alteration  of  the  features  may  suggest 
that  the  patient  has  hallucinations  which  he  is  dis- 
simulating. There  are  also  little  signs,  almost  too 
numerous  to  mention,  of  habitual  peculiarities  directly 
connected  with  the  patient's  insanity-  The  habit  of 
fingering  certain  portions  of  the  body  or  of  the  dress, 
the  movements  of  the  hands,  the  little  tricks  of  speech, 
unusual  employment  of  certain  words,  hesitation  as  if 
memory  were  weakened  in  certain  directions,  or 
specially  intensified,  and  most  of  the  minor  symptoms 
and  acts  varying  from  the  normal,  which  together 
make  up  what  has  been  called  insanity  of  manner,  all 
serve  to  aid  in  confirming  or  dispelling  suspicions 
already  aroused  by  the  history  and  patient's  testimony 
and  assertions. 

Hallucinations  are  not  always  easily  discovered 
objectively;  the  patient  may  absolutely  conceal  the 
fact  that  he  has  such,  and  in  suspicious  cases,  or  those 
in  which  distrust  is  a  strongly  pronounced  feature, 
this  difficulty  may  be  very  great.  As  auditory  hal- 
lucinations are  the  most  frequent  in  the  insane,  our 
attention  should  be  especially  given  to  any  evidence 
that  may  indicate  their  existence.  A  manner  as  if 
hearing  sounds,  or  the  habit  of  apparently  talking  to 
one's  self,  may  point  out  or  give  rise  to  strong  hints  of 
the  occurrence  of  hallucination  in  the  subject.  In 
spite  of  this,  however,  it  is  well  to  observe  the  patient 
when  off  his  guard,  when  he  thinks  he  is  not  being 
examined,  as  he  is  then  more  likely  to  betray  himself. 
This  can  be  done  by  questioning  him  on  an  entirely 
different  subject,  and  when  his  mind  is  entirely  di- 
verted from  the  subject  of  the  hallucination.  However, 
it  is  better  in  most  cases  to  carry  on  the  examination, 
if  possible,  at  different  times,  and  observe  the  patient 
unawares  to  make  sure  of  these  facts.  Any  peculiarity, 
also,  which  would  indicate  hallucination  of  the  other 


PSYCHIC    EXAMINATION    OF    THE    PATIENT.  93 

senses,  of  taste  or  smell,  which  are  not  so  important, 
may  be  sometimes  recognized  by  a  sniffling  or  spitting ; 
and  hallucinations  of  sight,  which  are  most  common 
in  delirious  cases,  are,  as  a  rule,  easier  to  detect  than 
those  we  have  mentioned.  It  must  not  be  understood 
that  the  patient  is  always,  or  even  generally,  averse 
to  speaking  of  these  facts,  or  what  appear  as  such  to 
him ;  and  if  his  confidence  can  be  gained,  as  it  ought  to 
be,  the  great  majority  of  the  genuinely  insane,  even 
though  they  may  have  a  more  or  less  suspicious 
tendency,  can  be  prevailed  upon  to  give  valuable  evi- 
dence on  these  points. 

Delusions  are  even  more  difficult  to  ascertain  than 
are  hallucinations,  and  it  may  take  weeks,  or  even 
months,  of  observation  in  an  asylum  to  fully  ascertain 
the  patient's  mental  state  in  this  regard.  As  a  rule, 
they  can  be  suspected  by  the  patient's  manner  and 
acts,  and  it  is  these  often  that  give  the  first  grounds 
for  suspicion  of  mental  unsoundness  in  case  of  para- 
noiacs.  Certain  forms  of  delusions  are,  of  course, 
readily  recognized ;  a  hypochondriacal  patient  is  ready, 
as  a  rule,  to  publish  his  ailments;  the  subject  of  delu- 
sions of  greatness  is  also  disinclined  to  conceal  them; 
the  delusions  of  the  melancholiac  are  sometimes  con- 
cealed, but  are  more  often  revealed  in  the  self-accusa- 
tory mood  of  the  individual.  The  persecutory  cases, 
on  the  other  hand,  are  sometimes  very  difficult  to 
study,  as  they  successfully  conceal  their  delusions, 
even  for  long  periods.  What  are  called  fixed  ideas 
are  also  possibly  concealed,  but  this  is  rare,  as  they  are 
generally  early  interpreted  by  the  acts  of  the  patient. 
Nevertheless,  there  may  be  a  suicidal  impulse  or  a 
homicidal  impulse  that  remains  entirely  concealed, 
and  therefore  cannot  be  guarded  against,  and  the  sub- 
ject is  more  important  when  such  impulses  as  these 
are  remittent,  only  occurring  at  intervals,  and  some- 
times only  for  very  short  periods.     They  exist  much 


94  GENERAL    DIAGNOSIS    AND    PROGNOSIS. 

more  generally  amongst  the  insane  than  is  sometimes 
stated,  and  are  to  be  looked  for  even  in  apparent  con- 
valescence. Many  of  the  suicides,  and  these  are  the 
most  dangerous  class,  occur  from  sudden  impulses  of 
this  kind. 

The  emotional  condition  of  the  patient  is  generally 
readily  seen ;  it  is  only  in  certain  mild  forms  of  depres- 
sive insanity  and  in  various  light  grades  of  mania  that 
it  is  likely  to  be  overlooked.  Mental  confusion  also  is 
usually  readily  recognizable,  as  are  also  the  various 
degrees  of  dementia  and  stupor. 

It  is  important,  whenever  practicable,  to  examine 
the  writing  of  the  individual  suspected  of  being  insane. 
It  will  very  often  afford  evidence  in  manner  or  matter 
of  his  mental  condition.  Paranoiacs  whose  speech 
and  general  behavior  give  no  signs  in  any  short  exam- 
ination, and  they  may  successfully  dissemble  for  weeks, 
are  often  completely  betrayed  by  their  letters  and  other 
writing.  The  tremor,  dropped  letters,  etc.,  of  paresis 
are  also  often  characteristic,  and  the  florid  style  of  the 
maniac  and  the  often  tremulous  slow  writing  of  the 
acutely  depressed  case  are  to  be  noted.  There  is  a 
germ  of  truth  in  the  pseudo-science  of  graphology  in 
that  penmanship  is  to  a  certain  extent  an  index  to  the 
emotional  state,  and  this  is  nowhere  more  marked  than 
in  some  of  the  insane.  It  is  important  in  this  connec- 
tion to  avail  one's  self,  if  possible,  of  a  comparison  of 
the  patient's  normal  writing,  as  it  may  indicate  prior 
eccentricities  as  well  as  show  the  changes  due  to  the 
disease. 

A  very  important  point  in  the  diagnosis  of  mental 
disorder  is  the  question  where  insanity  begins  and 
mental  soundness  ends.  It  is  in  these  doubtful  cases 
that  the  greatest  difficulties  are  met,  both  from  a 
medical  and  a  forensic  point  of  view.  There  are  mam- 
people  who  are  habitually  on  the  borderland  of  mental 
disease,  and  yet  who  cannot  be  called  actually  insane ; 


PSYCHIC    EXAMINATION    OF    THE    PATIENT.  95 

it  would  be  but  a  step  between  them  and  the  active 
lunatic,  and  yet  such  is  their  ordinary  condition  that 
it  is  difficult  to  say  when  that  step  is  taken.  Here 
the  past  record  and  previous  acquaintance  with  the 
patient's  condition  are  of  the  greatest  importance. 
AVhat  would  be  an  indication  of  insanity  in  one  man 
would  be  only  a  slight  aggravation  of  his  usual  state 
in  another.  We  must  always  compare  the  individual 
with  his  normal  self,  if  that  is  possible ;  and  where  that 
cannot  be  done  by  personal  observation  and  knowledge, 
we  must  utilize  all  available  facts,  not  merely  the 
testimony  of  friends  who  may  be  interested,  but  the 
consistency  of  his  present  condition  with  his  former 
occupations  and  position.  The  habits  of  the  indi- 
vidual, also,  must  be  carefully  considered,  and  no 
decision  be  made  in  any  case  on  too  brief  an  examina- 
tion. It  is  not  essential  to  say  just  what  form  of 
insanity  the  patient  suffers  from  if  evidence  is  sufficient 
to  show  that  he  or  she  is  not  his  or  her  normal  mental 
self. 

From  a  legal  point  of  view  the  individual  should  be 
given  the  benefit  of  the  doubt  in  these  uncertain  cases, 
as  a  rule,  according  as  the  decision  would  or  would  not 
constrict  his  liberty  of  action.  If  charged  with  crime, 
a  strong  suspicion  of  insanity,  though  it  be  not  clearly 
proved,  would  relieve  him  from  legal  responsibility; 
especially  would  this  be  the  case  if,  in  the  physical 
examination,  well-marked  degenerative  stigmata  could 
be  detected  in  such  number  as  to  place  him  below  the 
average  of  those  in  his  station  of  life.  On  the  other 
hand,  when  it  comes  to  a  question  of  civil  capacity, 
sanity  is  often  presumed  by  the  law,  even  against 
strong  evidence  of  mental  disturbance  and  degenera- 
tive signs. 

There  is  a  large  class  of  cases  which  may  or  may  not 
be  insanity;  cases,  for  instance,  of  sexual  perversion, 
which  may  be  due  to  pure  depravity,  and  in  such  cases 


96  GENERAL    DIAGNOSIS    AND    PROGNOSIS. 

as  these,  the  legal  question  may  sometimes  be  quite 
interesting.  The  same  is  true  of  habitual  intoxication 
and  its  results.  The  form  of  mental  degeneration 
which  reveals  itself  in  dipsomania  is  a  well-marked 
instance  of  this  class  of  cases,  which  sometimes  may  be 
acquired  on  a  slightly  defective  mental  basis,  or  may 
be  congenital  degeneracy.  There  are  many  insane  who 
are  never  regarded  as  such,  and  a  few  so  considered 
unjustly. 

In  examining  a  patient  to  ascertain  whether  or  not 
he  is  insane  it  is  not,  as  a  rule,  absolutely  necessary  to 
conceal  one's  object,  provided  the  examiner  is  skilled 
and  observant  and  uses  due  tact  in  his  examination. 
It  is  better,  however,  to  act  as  a  physician  inquiring 
after  health,  mental  as  well  as  physical,  and  the  special 
object  of  determining  the  insanity  need  not  be  obtruded 
unnecessarily.  An  insane  man,  however  suspicious  he 
may  be,  will  generally  be  better  impressed  with  an 
apparent  frankness  than  with  anything  that  appears 
to  him  as  artful  attempts  to  draw  him  out.  It  is  not 
always  necessary  to  state  to  him  that  he  is  suspected 
of  insanity,  but  it  is  seldom,  if  ever,  advisable  to  use 
deception  or  appear  before  him  in  a  false  character. 
As  a  rule,  a  suspicious  or  dissimulating  lunatic  has 
enough  of  that  practised  upon  him  by  the  laity,  and 
looks  for  it  everywhere,  so  that  he  is  more  often  taken 
off  his  guard  by  the  opposite  course.  It  is  impossible, 
however,  to  lay  down  any  specific  rules  to  be  followed, 
as  each  case  is  a  study  in  itself,  and  very  much  depends 
upon  the  tact  and  knowledge  of  human  nature  of  the 
physician.  It  must  always  be  remembered  that  there 
are  some  exceptional  cases  that  have  deceived  asylum 
physicians  and  attendants  with  all  their  opportunities 
for  observation,  at  least  for  considerable  periods,  in 
regard  to  their  mental  state. 

Prognosis. — From  what  has  been  said  in  the  chapter 
on  etiology  as  to  the  importance  and  frequency  of 


PROGNOSIS.  97 

predisposition  in  the  causation  of  mental  disease,  it 
may  be  readily  inferred  that  the  prognosis  of  insanity 
is  not  commonly  altogether  favorable.  This  is  espe- 
cially true  if  we  consider  the  possibilities  of  relapses 
as  well  as  the  outcome  of  the  actually  existing  attack. 
The  number  of  forms  of  mental  disorder  that  may  occur 
as  episodes  in  the  life  of  a  perfectly  normally  consti- 
tuted individual  is  small,  and  modern  studies  are 
reducing  rather  than  increasing  the  number.  As  the 
simplest  form  of  mental  affection,  we  may  count  febrile 
delirium,  which  occurs  many  times  in  the  lives  of  a 
large  proportion  of  the  population.  This  is  a  simple 
exhaustive  or  toxic  disturbance  of  cortical  function, 
and  is,  as  we  all  know,  transient  and  slight  in  its  after- 
effects. When  especially  severe,  however,  it  may 
leave  its  traces,  but  then  it  is  hardly  to  be  considered 
as  full-fledged  insanity.  The  patient  may  have  de- 
lirious recollections  which  are  as  real  to  him  in  after- 
life as  actual  recollections,  but  these  are  not  to  be 
considered  as  insane  delusions.  The  prognosis,  there- 
fore, of  simple  ordinary  delirium,  alone,  is  always  good. 

When,  however,  the  delirium  follows  a  condition  of 
profound  toxemia  or  exhaustion,  such  as  may  occur  in 
puerperal  conditions  and  various  febrile  disorders,  we 
have  a  genuine  insanity,  which,  if  not  accompanied 
by,  or  due  to,  a  marked  predisposition,  may  be  said  to 
occur  in  normal  individuals.  The  prognosis  of  these 
cases  depends  largely  upon  the  restoration  of  their 
normal  physical  condition,  and  if  the  prospect  of  this 
is  favorable,  the  prognosis  of  the  mental  disease  is  also 
reasonably  so.  In  some  cases,  however,  there  is  suffi- 
cient mental  damage  produced  to  make  the  case  a 
tedious  one  in  its  recovery,  and  recovery  sometimes 
only  partial  or  even  impossible. 

Sometimes  this  form  of  disease  may  occur  after 
intense  overstrain  or  exhaustion  in  an  otherwise 
healthy  individual,  but  even  then  it  is  so  connected 

7 


98  GENERAL    DIAGNOSIS    AND    PROGNOSIS. 

with  the  physical  conditions,  to  a  certain  extent,  as  to 
depend  upon  them  largely  with  regard  to  the  prog- 
nosis. Certain  forms  of  toxic  insanity,  also,  are  usually 
quickly  recovered  from,  and,  provided  predisposition 
is  absent,  may  be  considered  as  recoverable.  During 
the  special  developmental  periods,  also,  mild  forms  of 
neurasthenic  aberration  may  occur  and  yield  readily 
to  treatment,  but  care  should  be  taken  in  estimating 
the  future  of  these  cases  to  consider  all  degenerative 
possibilities.  The  developmental  insanities  are  not  by 
any  means  those  of  which  a  favorable  prognosis  can  be 
given. 

Simple  mania  and  melancholia  have  long  been 
reckoned  as  the  most  curable  forms  of  mental  disorder. 
Of  late  years,  however,  there  has  been  a  tendency  to 
adopt  a  slightly  different  view.  According  to  Pro- 
fessor Kraepelin,  mania  and  melancholia,  excepting 
the  latter  in  the  aged,  are  generally,  if  not  universally, 
based  upon  a  degenerative  taint,  and  their  recurrence 
is  almost  inevitable.  Their  prognosis,  therefore,  as 
regards  the  future  life  of  the  individual,  accepting 
these  views  as  correct,  can  hardly  be  called  a  good  one. 
As  regards  mania  in  its  truest  type,  separating  it  from 
cases  of  confusional  insanity,  etc.,  with  which  it  has 
been  often  confounded,  there  seems  to  be  considerable 
reason  in  Professor  Kraepelin's  views.  Melancholia, 
however,  including  all  the  milder  forms  which  exist 
and  hardly  come  under  the  observation  of  alienists, 
probably  includes  a  certain  number  of  cases  that  will 
not  correctly  fall  under  this  category  of  degenerative 
insanities.  The  point  is  a  new  one,  comparatively, 
and  further  and  wider  observation  will  be  required 
before  it  is  universally  accepted. 

Mania  is  certainly  hopeful  as  regards  the  immediate 
attack;  and  the  more  acute  the  attack,  as  a  rule,  the 
better  the  prognosis.  When  periodic  or  circular  in- 
sanity of  a  short  period  can  be  excluded,   one  may 


PROGNOSIS.  99 

generally  give  a  hopeful  opinion  as  regards  the  outcome 
of  the  attack.  Melancholia,  in  the  forms  under  which 
it  comes  in  the  care  of  asylum  physicians,  is  also  hopeful 
as  regards  recovery  from  the  attack,  and  there  is  less 
reason  to  be  discouraged,  even  after  it  has  existed  for 
a  long  period,  than  is  the  case  with  most  other  forms 
of  insanity.  Predisposition,  of  itself,  does  not  neces- 
sarily affect  the  prospects  of  recovery  from  the  im- 
mediate attack,  and  where  there  is  no  predisposition, 
it  must  be  also  borne  in  mind  that  the  damage  done 
the  brain  by  the  attack  may  conduce  to  a  state  of 
weakness  that  will  favor  future  attacks.  Insanity  is 
least  of  all  a  self-protective  disease. 

When  serious  organic  changes  have  occurred,  and 
insanity  depends  upon  them,  as  in  the  various  forms 
of  organic  mental  disease,  the  prognosis  is  neces- 
sarily bad.  In  toxic  insanities,  where  brain  damage 
has  ensued,  the  prognosis  naturally  depends  upon 
the  degree  of  the  latter,  and  may  be  favorable  or 
otherwise.  In  alcoholism  and  alcoholic  insanity,  also 
that  due  to  morphin,  cocain,  etc.,  the  possibility 
of  predisposition  is  always  to  be  kept  in  mind. 
Certain  forms  of  apparently  acute  insanity  occur- 
ring in  old  age  also  sometimes  undergo  a  cure, 
though,  as  a  rule,  their  outcome  is  not  favorable.  In 
secondary  dementia  the  prognosis  is  almost  universally 
bad,  but  there  are  occasionally  surprising  recoveries — 
striking  exceptions  to  the  rule.  In  no  case  is  it  abso- 
lutely safe  to  say  that  recovery  is  impossible,  unless 
we  know  that  irreparable  damage  has  been  done  to 
the  mentally  functioning  portions  of  the  brain. 


CHAPTER  VIII. 

GENERAL  THERAPEUTICS. 

The  first  question  that  arises  when  a  case  of  insanity 
is  diagnosed  is  where  it  shall  be  treated,  at  home  or  in 
a  public  or  private  institution  for  the  insane.  In  cases 
of  acute  maniacal  excitement  this  question  is  usually 
readily  answered,  as  there  are  few  families  that  are  in 
condition,  financial  or  otherwise,  to  care  for  and  have 
treated  amongst  them  an  acute  maniac.  For  the  great 
majority  of  the  people  the  public  institutions  for  the 
insane  are  an  inestimable  blessing,  as  they  afford  the 
means  of  caring  for  those  who  cannot  be  cared  for  by 
their  relatives  or  treated  to  advantage  by  physicians 
at  their  homes.  Cases  of  agitated  melancholia,  also, 
and  generally  in  cases  where  there  is  decided  mental 
or  motor  excitement  the  asylum  is  almost  the  only 
resource.  To  those  who  have  unlimited  means  and 
when,  through  prejudice,  family  pride,  or  otherwise, 
the  use  of  a  public  or  private  institution  is  objected 
to,  home  treatment  is  possible,  but  under  disadvan- 
tages. The  question  of  expense  is,  of  course,  the  first 
one  to  be  settled,  but  no  amount  of  expenditure  will 
make  it  possible  to  give  the  patient  some  of  the  advan- 
tages which  can  be  had  in  a  well-managed  hospital  for 
the  insane.  The  mere  fact  that  he  is  kept  amongst 
his  accustomed  surroundings  is  a  drawback  by  itself. 
The  complete  change  from  home  life  to  hospital  life, 
the  discipline  and  routine  of  the  latter,  and  the  moral 
effect  of  judicious  and  kindly  control  which  can  be 
there  obtained,  are  impossible  to  be  provided  in  the 
patient's  home,  where  distraction  of  various  kinds, 
the  old   habits  of   authority  and   responsibility,  and 


HOME    AND    ASYLUM    CARE.  IOI 

the  lack  of  judgment  often  shown  by  relatives  and 
friends,  all  contribute  to  hinder  and  embarrass  the 
treatment.  It  is  also  to  be  considered  that  when 
insanity  exists  in  a  family  it  means,  to  some  extent  at 
least,  a  family  taint,  and  the  disadvantages  of  the 
detention  of  an  insane  person  amongst  others  of  various 
ages  and  conditions  of  health,  who  may  themselves  be 
susceptible  to  mental  disorders,  cannot,  in  any  case, 
be  considered  as  altogether  advisable.  This  same 
family  predisposition  often  displays  itself  in  a  sort  of 
unreasonableness  that  embarrasses  the  doctor,  and 
prevents  him  from  using  the  means  that  are  most 
advantageous  to  his  patient.  With  the  best  intentions 
for  their  afflicted  relative,  the  family  and  friends  of  the 
patient  are  often  capable  of  doing  him  infinite  damage 
by  their  misdirected  interference  and  sympathy. 

In  a  very  large  class  of  cases,  however,  the  question 
of  asylum  treatment  as  opposed  to  home  treatment  is 
a  still  more  difficult  one  to  settle.  Among  these  we 
may  include  the  milder  cases  of  melancholia,  a  large 
proportion  of  which  never  go  into  any  public  or  private 
institution,  but  are  simply  office  cases  of  the  family  or 
specialist  physician.  In  the  majority  of  instances  of 
this  kind  recovery  probably  occurs,  and  they  are  not 
included  in  any  statistics  of  insanity.  The  disorder 
may  be  purely  emotional,  there  may  be  no  intellectual 
aberration  whatever,  the  patient  may  continue  his 
ordinary  occupation  without  any  serious  interruption, 
and,  while  his  depression  is  noticeable,  no  one  thinks 
it  serious  enough  to  demand  his  sequestration.  It  is 
just  these  cases,  however,  that  furnish  the  tragedies 
that  we  read  of  from  time  to  time  in  the  daily  press; 
they  are  the  suicides,  or  combined  suicides  and  homi- 
cides, and  it  must  be  remembered  that  the  successful 
cases  probably  form  only  a  small  proportion  of  the 
number  of  attempts.  It  is  exceedingly  difficult  in 
some  of  these  cases  to  say  exactly  what  is  to  be  done ; 


102  GENERAL    THERAPEUTICS. 

the  patient  is  so  rational,  has  such  perfectly  clear  ideas 
in  some  respects  as  to  his  condition,  and  denies  any 
suicidal  tendency,  that  it  would  seem  unjust  to  recom- 
mend any  restriction  of  his  liberty.  In  other  cases, 
even  where  a  suicidal  tendency  is  admitted  by  the 
patient,  the  danger  may  be  no  greater.  It  does  not 
follow  because  a  person  denies  such  intention  that  he 
may  not  under  the  influence  make  the  attempt.  The 
best  plan  probably  in  these  doubtful  cases  is  to  advise 
the  retirement  to  a  sanitarium  or  hospital  where  the 
patient  can  go  voluntarily  without  incurring  the 
stigma,  as  it  is  popularly  regarded,  of  insanity,  have  a 
certain  degree  of  liberty,  and  yet  be  under  close  medical 
observation,  and  where  a  certain  amount  of  restraint 
may  be  exercised  should  it  prove  absolutely  necessary. 

The  general  hospitals  that  are  to  be  found  in  all 
cities  and  in  many  enterprising  towns  furnish  admir- 
able places  for  at  least  the  temporary  care  and  treat- 
ment of  many  cases.  They  furnish  excellent  medical 
attendance,  good  nursing,  and  can  be  promptly  made 
use  of  without  any  legal  formalities.  There  is  a  need 
of  a  larger  number  of  this  class  of  institutions  for  such 
cases  as  these,  and  it  is  a.  misfortune  that  there  are  not 
more  of  them,  and  that  they  are  not  within  the  means 
of  a  larger  number  of  patients  of  this  kind.  Where  this 
is  not  possible,  it  is  well  to  advise  the  friends  fully  as 
to  the  patient's  condition,  so  that  they  will  be  on  their 
guard  against  any  possible  attempt  at  self -injury.  In 
many  cases  the  attacks  are  temporary,  and  are  only 
indications  of  an  insane  predisposition,  which  is  liable 
to  crop  out  at  any  time. 

Cases  of  stuporous  insanity  and  of  acute  confusional 
insanity  without  violence,  and  a  large  class  of  cases 
attended  with  serious  bodily  weakness,  can  be  treated 
at  home.  The  same  is  true,  to  some  extent,  with 
organic  dementia,  certain  stages  of  paresis,  and  some 
cases  of  epileptic  insanity.     The  inconveniences,  how- 


HOME    AND    ASYLUM    CARE.  103 

ever,  especially  in  organic  and  paretic  insanities,  are 
very  great,  and  home  treatment  is  not  advisable  unless 
good  nursing  facilities  are  attainable,  and  within  the 
means  of  the  patient  or  his  friends.  As  a  rule,  all  other 
cases  are  better  cared  for  in  some  institution  for  the 
special  treatment  of  insanity.  Paranoia  is  a  type  of 
insanity  which  is  often  so  insidious  in  its  onset,  and 
develops  so  gradually,  that  the  question  of  asylum  or 
home  treatment  does  not  arise  until  after  the  patient's 
delusions  have  induced  him  to  commit  some  act  of 
violence  or  impropriety  that  renders  his  insanity 
obvious.  If  the  delusions  are  of  the  persecutory  type, 
it  is  certainly  advisable  that  the  patient  be  seques- 
trated and  placed  where  he  can  do  no  possible  harm. 
There  are  many  paranoiacs  at  large  who  ought  to  be 
under  restraint,  but  the  public  seldom  realizes  this  fact 
until  after  some  tragedy  has  occurred,  and  then  pre- 
judice and  passion  are  as  liable  to  lead  to  the  unjust 
punishment  of  the  lunatic  as  they  are  to  his  rational 
treatment  by  commitment  to  an  asylum.  One  danger 
in  such  cases  is  the  influence  of  example;  after  one 
of  these  cranks,  as  they  are  popularly  called,  has 
committed  some  crime  or  act  of  violence,  especially 
upon  a  conspicuous  person,  others  are  likely  to  follow 
his  example,  or  make  attempts  to  do  so.  This  was 
especially  noticeable  about  the  country  after  the 
assassination  of  President  Garfield  by  Guiteau,  and 
of  Mayor  Harrison  by  Prendergast,  both  of  whom  were 
well-marked  degenerative  paranoiacs. 

When  home  treatment  seems  unavoidable  if  not  ad- 
visable, the  measures  to  be  taken  depend  mainly  upon 
the  special  character  of  the  case.  In  those  cases  where, 
through  prejudice,  fear,  or  family  pride,  keeping  an 
acutely  excited  insane  person  at  home  is  insisted  upon, 
the  first  thing  to  be  seen  to  is  proper  attendance.  It 
is  not  always  easy  to  obtain  good  attendants  for  the 
insane  at  home.     If  the  patient  is  physically  ill  and 


104  GENERAL    THERAPEUTICS. 

weak,  good  nursing  and  care  by  trained  nurses  may 
sometimes  meet  the  requirements,  especially  if  the  con- 
dition is  such  that  the  patient  can  be  confined  to  his 
bed.  Trained  nurses,  however,  have  not,  generally, 
all  the  qualifications  required  for  the  proper  care  of  the 
insane,  and  require  to  be  closely  watched  and  elabor- 
ately instructed  by  the  physician.  Besides  the  mere 
nursing,  the  precautions  in  regard  to  possible  attacks 
of  violence,  insane  impulses  toward  suicide,  etc.,  should 
be  impressed  upon  their  minds.  They  should  leave 
no  medicines  within  reach,  and  any  object  or  article 
that  may  be  dangerous  should  be  carefully  kept  out  of 
the  patient's  hands,  and  they  should  be  selected,  if 
possible,  for  their  kindly  and  patient  disposition, 
together  with  a  certain  power  of  control  of  others  that 
can  be  exercised  if  needed.  They  should  be  impressed 
with  the  fact  that  the  patient  is  something  more  than 
a  sick  person,  and  should  be  made  to  modify  their 
management  accordingly.  The  care  of  the  insane  is 
much  more  trying  in  many  ways  than  that  of  the  sick, 
and  it  is  not  every  trained  nurse,  however  competent 
in  her  special  line,  that  is  fit  to  undertake  it.  If  the 
patient  is  a  man,  and  especially  if  he  has  considerable 
muscular  power,  and  is  at  all  inclined  to  be  violent,  a 
male  nurse  should  be  at  hand.  All  these  things  involve 
a  large  expense,  and  they  also  require  special  arrange- 
ments of  rooms,  which  should  be  distant  from  the 
other  inhabited  portions  of  the  house,  if  this  is  prac- 
ticable. 

Summing  up,  the  home  treatment  of  the  insane  is 
dependent  both  upon  the  character  of  the  case  and  the 
means  of  the  family  or  friends.  When  proper  attend- 
ance can  be  secured  and  the  needed  arrangements  be 
made  at  the  home,  it  is  possible  to  care  for  acutely 
insane  individuals  outside  of  an  institution.  When 
means  are  insufficient,  it  is  impossible  to  give  them 
the  proper  care,  and  this  is  true  in  the  vast  majority 


HOME    AND    ASYLUM    CARE.  105 

of  cases.  Chronic  insane  of  the  milder  type  can  be 
cared  for  in  private  families,  and  require  generally 
no  special  medical  treatment  except  for  incidental 
ailments.  Medical  oversight,  however,  should  be  con- 
sidered essential,  and  it  is  not  safe  to  leave  the  patient 
entirely  to  the  care  of  friends,  however  well  intentioned, 
without  this.  An  insane  individual  is  always  to  some 
extent  uncertain  as  to  his  conduct,  and  in  many  cases 
explosions  of  active  insanity  are  liable  to  occur.  In 
other  cases  their  habits  and  tendencies  are  such  as  to 
make  it  necessary  that  some  special  oversight  is  given, 
and  in  the  country  and  amongst  persons  ignorant  as  to 
this  class  of  disorders  severer  measures  than  are  neces- 
sary are  liable  to  be  employed.  The  family  care  of  the 
chronic  insane  is  largely  practised  in  certain  foreign 
countries,  notably  Belgium  and  Scotland,  and  with 
success,  but  in  all  cases  under  medical  supervision. 
In  this  country  it  has  not,  as  yet,  been  extensively 
tried,  and  it  requires  a  special  class  of  permanent  popu- 
lation to  whom  this  becomes  a  sort  of  natural  employ- 
ment, and  who  are  in  a  measure  specially  trained  to  it. 
In  this  country  we  have,  in  most  parts,  at  least,  too 
fluctuating  a  population,  and  it  will  take  time  at  least 
before  we  can  establish  proper  systems  of  family  care. 
There  is  still  another  consideration  to  be  borne  in 
mind  when  discussing  the  home  treatment  of  insanity : 
that  is,  the  influence  of  the  insane  upon  the  other 
members  of  the  family.  In  a  very  large  proportion  of 
cases,  as  has  been  already  shown,  the  outbreak  of 
mental  disease  in  any  member  of  the  family  is,  to  a 
certain  extent,  a  result  of  a  family  taint,  which  is  in- 
herited not  only  by  the  afflicted  individual,  but  by  his 
near  relatives.  The  effect  of  an  insane  member  of  the 
family  living  in  close  relations  with  the  rest,  who  are 
themselves  somewhat  predisposed,  and  some  of  whom 
are  of  an  impressible  and  receptive  age,  subject  to 
various  influences   that   may   affect   them,    is   not  in 


106  GENERAL    THERAPEUTICS. 

itself  a  desirable  one,  and  may  be  at  times  disastrous. 
We  have  observed  decided  mental  disturbance  occurring 
in  the  members  of  a  family  in  which  an  insane  brother 
was  retained  at  home  instead  of  being  sent  to  a  public 
or  private  institution,  and  such  instances  are  more 
common  than  are  reported.  This  appears,  at  least,  a 
consideration  worthy  of  attention  on  the  part  of  the 
physician  when  the  question  of  home  treatment  is  left 
to  his  decision. 

Whether  an  insane  patient  is  treated  at  home  or  in  an 
institution  for  the  insane,  or  in  an  ordinary  hospital, 
the  general  indications  for  treatment  are  the  same. 
We  have  to  meet  conditions  of  excitement  or  depres- 
sion, special  motor  activity  or  stuporous  passivity, 
refusal  of  food,  deprivation  of  sleep  and  rest,  and 
general  derangement  of  the  vegetative  functions  of  the 
organism.  Each  of  these  conditions  requires  to  be  met 
and  remedied.  The  most  obvious  indication  at  first 
sight  in  a  case  of  acute  mania  is  apparently  to  quell 
or  modify  the  abnormal  mental  and  physical  excite- 
ment, which  not  only  renders  the  patient  difficult  to 
manage,  but  seems  liable,  if  continued,  to  exhaust  his 
powers.  It  may  be  a  question  sometimes  whether 
this  is  as  necessary  as  it  appears,  especially  in  well- 
nourished,  physically  healthy  individuals.  The  motor 
excitement  may  be  in  its  way  conservative,  and  assist 
in  working  off  the  mental  excitability.  It  is  expedient, 
however,  in  most  of  these  cases,  and  will  be  found  very 
generally  necessary,  in  caring  for  these  cases  at  home, 
to  do  something  to  quiet  the  individual,  and  at  all 
events  to  secure  the  needed  rest.  Frequently  this 
result  can  be  obtained  by  giving  the  patient  a  warm 
bath  just  before  retiring  time,  and  continuing  it  for 
fifteen  or  twenty  minutes.  It  is,  in  fact,  a  good  treat- 
ment for  any  such  case  of  insanity  to  use  this  means, 
especially  the  first  night.  The  water  should  be  warm, 
about  9 8°  F.,  and  if  the  excitement  is  very  great,  cold 


MEDICAL    TREATMENT.  107 

applications  may  be  applied  to  the  head.  Under  the 
combined  influence  of  these,  together  with  a  warm 
draught  of  milk,  with  sometimes  a  little  alcohol  added, 
a  good  night's  sleep  may  be  obtained  and  the  patient  be 
much  better  both  physically  and  mentally  in  the  morn- 
ing. The  necessity  of  sleep  in  these  cases  is  very  great. 
The  patients  sometimes  keep  abnormally  wakeful  for 
days  unless  something  is  done  to  relieve  them.  Com- 
monly it  will  be  found  necessary,  however,  to  supple- 
ment this  with  some  hypnotic.  Of  these,  the  one  that 
has  been  longest  in  favor,  and  is  certainly  reliable, 
though  not  without  its  dangers,  is  chloral,  in  doses  of 
10  to  20  grains.  It  is  sometimes  advantageous  to 
combine  this  with  bromid  of  sodium,  the  amount  of 
20  or  30  grains  to  the  dose.  The  combined  effect  is 
somewhat  better  than  that  of  the  chloral  alone.  It  is 
not  desirable  to  exceed  20  grains  of  chloral  at  a  dose, 
nor  to  repeat  it,  if  this  is  found  insufficient,  as  its 
action  on  the  heart  is  sometimes  unpleasant  and 
dangerous,  and  the  large  doses  that  were  formerly 
given  of  30,  40,  and  60  grains  are  often  really  perilous 
to  life.  In  many  cases  30  or  40  grains  of  sodium 
bromid  alone  is  sufficiently  quieting  after  the  warm 
bath,  especially  if  these  are  given  at  night  when  the 
patient  is  not  likely  to  be  disturbed  by  external  sights 
or  noises.  Other  remedies  that  maybe  combined  with 
the  bromid  in  some  cases  are  ergot,  in  doses  of  half  a 
dram,  and  in  some  rare  instances,  in  mania,  a  mod- 
erate dose  of  opium  may  be  combined,  but,  ordin- 
arily, this  is  not  needed  or  desirable  in  these  cases.  In 
anxious  melancholia,  however,  where  sleeplessness  and 
agitation  are  prominent  symptoms,  opium  is  more 
useful;  its  value  is  manifested  chiefly  in  cases  where 
the  element  of  pain  exists,  and  this  is  a  prominent 
feature  in  most  cases  of  melancholia.  Morphin  given 
hypodermically  is  still  better  as  a  reducer  of  pain, 
especially  in  cases  where  that  peculiar  pneumogastric 


108  GENERAL    THERAPEUTICS. 

neurosis  called  precordial  anguish  or  distress  is  a 
prominent  symptom.  Opium,  however,  requires  to  be 
used  with  care,  and  its  value  as  a  simple  sedative  and 
sleep-producer  is  limited  chiefly  to  these  special  cases. 
Other  hypnotics  that  have  been  in  common  use  are 
paraldehyd,  which  is  a  safer  remedy,  on  the  whole,  than 
chloral,  though  less  effective  and  not  so  permanent  in 
its  effect.  It  has  also,  with  chloral,  the  disadvantage 
of  a  disagreeable  taste,  which  is  especially  objected 
to  by  some,  and  also  the  effect  of  producing  sometimes 
gastric  irritation.  Chloralamid  is  another  remedy, 
transient  in  its  action,  but  often  effective  in  producing 
sleep,  which  may  continue  of  itself  if  not  disturbed. 
One  of  the  most  reliable,  however,  of  modern  hypnotics 
is  sulphonal,  which  has  also  the  advantage  of  being 
tasteless,  and  therefore  more  easily  administered.  It 
is  slower  in  its  effect  than  most  of  the  other  drugs 
mentioned,  and  should  therefore  be  given  a  little  while 
before  the  hour  of  retiring.  As  a  rule,  10  grains  may 
be  found  effective,  but  15  or  even  20  can  be  safely 
used  for  single  doses.  In  some  obstinate  cases  of 
sleeplessness  a  combination  of  bromid,  sulphonal,  and 
chloralamid,  not  in  mixture,  but  given  separately  at 
different  times,  is  effective.  The  sulphonal  can  be 
given  about  four  or  five  o'clock  in  the  afternoon;  the 
bromids,  preferably  the  bromid  of  sodium,  between 
supper  and  bedtime;  and  the  chloralamid  directly  on 
retiring;  the  latter  exercises  its  hypnotic  effect  im- 
mediately, and  the  continuance  of  sleep  is  secured  by 
the  slower  action  of  the  other  drugs.  The  disad- 
vantages of  sulphonal  are  the  unpleasant  symptoms 
that  are  sometimes  produced,  in  the  way  of  dizziness, 
ataxia,  etc.,  and  the  drowsiness  that  sometimes  follows 
on  the  day  after  its  use,  and  its  interference  with 
digestion  as  well  as  its  more  serious  damaging  effects 
from  long-continued  use. 

Trional,  which  is  similar  in  its  effects  to  sulphonal, 


MEDICAL    TREATMENT.  109 

and  has  some  of  its  advantages,  may  be  substituted 
for  it.  In  the  cases  of  mania  and  agitated  melancholia, 
hyoscin  hydrobromate,  either  alone  or  in  combination 
with  sulphonal,  will  often  produce  sleep  when  other 
agents  fail. 

In  some  cases  where  simple  irritability  produces 
wakefulness,  a  slight  stimulant  will  tide  the  patient 
over  and  produce  healthful  sleep.  The  well-known 
effect  of  an  alcoholic  night-cap  is  based  on  this  fact, 
and  in  some  cases  of  insanity  where  this  kind  of  sleep- 
lessness exists,  a  dram  or  two  of  alcohol  in  a  glass  of 
milk  at  bedtime  will  be  sufficient  to  produce  the 
desired  effect.  With  alcohol,  it  is  desirable  to  keep 
this  within  the  physician's  own  hands,  and  avoid 
anything  like  the  possibility  of  producing  or  exciting 
a  dormant   alcoholic  habit. 

The  list  of  hypnotics  within  the  last  few  years  has 
become  a  rather  long  one,  but  those  mentioned  are  the 
chief  ones,  and  furnish  sufficient  resources  to  meet  the 
needs  in  almost  any  case  of  actual  insanity.  One 
point  must  be  remembered,  that  in  the  use  of  any  of 
these  remedies  it  is  necessary  to  avoid  a  depend- 
ence upon  them,  and  it  is  well,  whatever  drug  is 
used,  to  intermit  its  employment  from  time  to  time 
and  see  if  the  patient  cannot  obtain  sleep  without  it. 
Frequently  one  or  two  doses  having  produced  their 
effects,  nature  will  take  care  of  itself,  and  the  patient 
sleep  without  their  use.  It  is  not  absolutely  necessary 
to  insure  the  patient's  sleeping  through  the  night 
continuously,  and  an  occasional  sleepless  night  in  case 
of  mania  is  not  to  be  specially  dreaded,  though  it 
should  be  avoided,  if  possible.  It  is  Avell  at  times  to 
change  the  remedy,  so  that  the  patient  will  not  become 
too  much  accustomed  to  any  one  drug.  In  this  way 
we  avoid  the  evil  of  setting  up  a  toleration  which  will 
require  increased  doses  to  produce  the  usual  effect. 


IIO  GENERAL    THERAPEUTICS. 

Hypnotics  at  best  are  only  a  makeshift  to  tide  over  a 
disagreeable  symptom,  for  which  nature  herself  pro- 
vides the  relief  often  in  many  cases. 

What  has  been  said  in  regard  to  hypnotics  leads 
naturally  to  the  discussion  of  the  use  of  sedatives  to 
quiet  mental  or  motor  excitement  during  the  waking 
period.  The  drugs  mostly  employed  for  this  purpose 
are  the  bromids,  ergot,  conium,  hyoscin  hydrobromate, 
and  in  late  years  the  sulphate  of  duboisin.  The 
bromids  are  a  general  sedative  if  only  applied  in  quiet- 
ing the  less  excited  cases.  For  the  extreme  excite- 
ment something  more  powerful  is  generally  required. 
For  this  purpose  hydrobromate  of  hyoscin  in  very 
minute  doses  has  been  very  largely  employed;  the 
amount  given  hypodermically  should  not  exceed,  at 
the  very  most,  T^  grain,  and  the  same  is  true  of 
duboisin.  Caution  should  be  observed  against  too 
great  depression  following  the  use  of  these  drugs  in 
every  case.  Conium,  when  the  preparation  is  a  reli- 
able one,  is  an  excellent  motor  sedative;  a  useful  com- 
bination is  10  minims  each  of  Squibb's  fluid  extract  of 
conium  and  hyoscyamus,  together  with  10  grains  of 
chloral  in  one  dose.  This  is  often  exceedingly  effec- 
tive, though  sometimes  slightly  larger  quantities  are 
required;  the  patients  receiving  it  while  in  the  most 
acute  excitement  often  become  quiet  and  tranquil, 
and  sometimes  its  use  is  followed  by  a  long  period  of 
sleep.  It  occasionally  happens  in  acutely  excited  con- 
ditions that  the  patient  is  almost  ready  to  break  down 
from  fatigue,  and  at  such  times  a  very  much  smaller 
dose  than  usual  of  any  powerful  sedative  will  produce 
unexpected  effects.  Nature  sometimes  reasserts  her- 
self without  the  use  of  drugs,  and  if  we  anticipate  this 
by  giving  a  powerful  remedy,  we  may  find  ourselves 
in  the  presence  of  alarming,  if  not  really  dangerous, 
symptoms. 

The  use  of  sedatives  has  been  somewhat  discouraged 


MEDICAL    TREATMENT.  Ill 

in  times  past,  and  there  is  no  doubt  but  that  they  have 
been  overused,  there  being  so  constant  a  temptation  to 
relieve  the  very  marked  symptoms  of  excitement. 
They  have  no  specially  curative  effect  in  themselves, 
and  their  real  value  is  in  preventing  the  patient's 
exhaustion,  and  in  relieving  the  inconvenience  to  others 
which  the  excitement  produces.  They  should  be  used 
with  caution  in  any  case,  and  not  relied  upon  habitu- 
ally. It  is  better  to  endure  the  noise,  and  to  allow  a 
certain  amount  of  action,  than  to  attempt  to  repress 
it  unduly  when  the  patient  is  in  good  physical  con- 
dition. 

Other  medicines  that  are  advised  in  insanity  and 
that  have  their  uses  in  special  phases  will  be  noticed 
more  particularly  in  the  special  part  of  this  work.  It 
may  be  said  here,  however,  that  in  a  large  number  of 
these  cases  a  tonic  treatment  is  advisable,  and  for 
remedies  of  this  kind  the  best  are  probably  quinin, 
iron,  strychnin,  and  arsenic.  These  can  be  given  with 
profit  in  depressed  conditions,  and  strychnin  is  par- 
ticularly indicated  in  certain  forms  of  depressed  toxic 
insanities. 

Aside  from  the  strictly  medical  treatment,  a  large 
number  of  remedial  measures  are  demanded  in  caring 
for  the  insane.  One  of  the  first  things  to  be  remem- 
bered is  that  it  is  an  exhausting  disease,  especially  in 
its  acute  form,  and  that  the  waste  of  the  system  must 
be  made  up.  This  is  the  more  important  since  the 
voluntary  cooperation  of  the  patient  is  often  out  of  the 
question,  and  that,  too,  in  the  cases  where  good 
nourishment  is  more  particularly  demanded  by  his 
condition.  Melancholiacs,  especially  in  the  more 
marked  type,  almost  habitually  refuse  food.  They  do 
this  sometimes  from  a  delusion,  but  very  often  there 
is  a  complete  loss  of  appetite,  and,  more  than  this, 
an  unconquerable  repugnance  to  food  of  every  kind. 
In  acute  mania  the  patient   is  often  too   excited  to 


112  GENERAL    THERAPEUTICS. 

think  of  his  bodily  wants,  and  will  neglect  his 
meals,  and  actually  starve,  if  not  attended  to.  In 
other  forms  of  insanity,  like  certain  delusional  cases, 
whether  accompanied  with  depression  or  agitation, 
everything  that  is  offered  is  thought  to  be  poison  or 
repulsive,  and  is  obstinately  refused.  In  the  milder 
forms  of  depression,  as  in  confusional  cases  and  ex- 
haustion delirium,  the  appetite  is  weakened  or  lost, 
but  there  is  not  always  the  resistance  to  being  fed  that 
is  met  with  in  some  of  the  other  types.  In  these  cases, 
however,  more  than  almost  any  others,  there  is  need 
of  building  up  the  system,  and  regular  administration 
of  food  is  almost  the  essential  part  of  the  cure.  In 
acute  delirium  it  is  the  only  thing  that  will  carry  the 
patient  through,  notwithstanding  the  fact  that  it  is 
seldom  easy  to  administer  it.'  In  many  cases  food  is 
simply  refused,  or  is  neglected  by  the  patient,  but  will 
be  taken  if  administered  by  the  attendant.  Some- 
times there  is  a  sort  of  passive  resistance  that  is  easily 
overcome.  In  other  cases,  still,  the  resistance  is  more 
active,  and  a  certain  degree  of  force  is  required.  When 
the  food  cannot  be  given  by  a  spoon,  a  feeding-cup 
with  a  short  nozzle  which  is  introduced  into  the  mouth 
will  be  useful.  With  perseverance  and  tact  many  of 
these  cases  can  be  fed  in  this  way,  though  at  first  it  may 
seem  impossible.  When  all  other  methods  fail,  however, 
artificial  feeding,  by  means  of  the  stomach-tube,  must 
be  resorted  to,  and  in  some  cases  this  cannot  be  done 
too  early,  or,  rather,  it  may  easily  be  put  off  until  too 
late.  The  methods  of  using  the  stomach-tube  are  two 
in  number,  either  by  the  mouth  or  through  the  nostril. 
Feeding  by  the  mouth  is  performed  by  forcing  the 
mouth  open  and  keeping  it  thus,  while  the  esophageal 
tube  is  passed  down  through  the  pharynx  into  the 
stomach,  the  food  itself  being  poured  into  a  funnel  or 
injected  by  means  of  a  fountain  syringe.  This  method 
often  requires  the  use  of  much  force  in  opening  the 


ARTIFICIAL    FEEDING.  113 

mouth,  and  sometimes  there  is  danger  of  breaking 
teeth,  or  bruising  the  soft  parts.  Its  advantage  is  that 
the  esophageal  tube,  once  that  the  passage  is  open,  is 
easily  introduced;  it  should,  if  of  the  ordinary  linen 
construction,  be  well  softened  in  warm  water,  so  that 
it  is  perfectly  flexible,  and  yet  have  it  still  possess  enough 
rigidity  to  guide  itself  into  the  gullet.  Its  size  is  such 
that  the  danger  of  its  engaging  in  the  larynx  is  very 
slight,  and  the  chances  of  the  food  being  introduced 
into  the  lungs  by  accident  are  negligible.  Any  one 
can  put  down  the  esophageal  tube,  once  the  mouth 
is  fixed  in  the  open  position,  but  this  often  requires 
constant  use  of  force  and  struggle  with  the  patient, 
and  the  use  of  some  restraining  apparatus  or  sufficient 
manual  force  is  absolutely  necessary  in  most  cases. 
There  is  a  disadvantage  that  in  case  the  gag  should 
slip  out  of  the  mouth,  the  patient  may  bite  the  tube 
in  two,  and  this,  with  the  apparent  roughness  which  is 
required  in  its  use,  is  a  serious  inconvenience. 

The  use  of  the  nasal  tube  has  many  advantages  over 
the  other.  The  patient  cannot  stop  the  passage,  and 
struggling  and  possible  injury  to  the  mouth  and  teeth 
need  not  be  considered.  Of  course,  restraining  appa- 
ratus will  be  required,  the  same  as  with  the  other,  to  hold 
the  patient,  but  this  part  of  the  operation  is  compara- 
tively simple.  The  tube  should  be  of  the  largest  size 
that  can  be  passed  through  the  nostril,  and  should  be 
perfectly  flexible ;  soft  rubber  is  the  best  material.  Its 
disadvantages  are  that  it  requires  some  skill  and 
practice  to  introduce  it,  and  in  some  patients  it  is  very 
difficult  to  guide  it  through  the  proper  channel.  The 
second  disadvantage,  and  a  serious  one,  is  the  possi- 
bility of  its  engaging  in  the  vocal  cords ;  and  if  care  is 
not  taken,  there  is  danger  of  the  introduction  of  the 
food  into  the  trachea  and  lungs,  with  consequent  pro- 
duction of  an  aspiration  pneumonia. 

If  the  tube  is  small  and  is  not  tightly  grasped  by 


114  GENERAL    THERAPEUTICS. 

the  muscular  walls  of  the  gullet,  the  liquid  may  be 
regurgitated,  and  in  this  way  reach  the  air-passages, 
producing  the  same  effect  with  equally  disastrous 
consequences.  When  this  happens,  which  can  gener- 
ally be  told  by  symptoms  of  suffocation  and  coughing 
on  the  part  of  the  patient,  the  tube  should  be  im- 
mediately withdrawn,  and  the  oral  method  of  treatment 
adopted  instead  of  the  nasal  tube. 

The  material  used  in  forced  feeding  must  necessarily 
be  liquid,  and  there  is  no  better  to  be  had  than  milk 
and  eggs ;  one  or  two  eggs  beaten  up  in  a  quart  of  milk 
and  given  twice  or  three  times  daily  will  suffice  in  most 
cases,  though  in  some  depressed  cases  overfeeding  is  a 
decidedly  advantageous  procedure,  and  Dr.  Clouston 
mentions  cases  where  as  much  as  three  quarts  and 
sixteen  eggs  have  been  given  daily,  with  great  advan- 
tage to  the  patient.  The  fluid  should  be  slightly 
warmed  before  introduction,  and  may  be  used  as 
directed  with  a  fountain  syringe  or  funnel,  or  an  ordin- 
ary bulb  syringe  may  be  employed.  It  is  advisable, 
also,  in  case  the  latter  is  used,  to  have  the  tube  well 
secured  to  the  nozzle,  as  in  case  of  any  obstruction 
occurring  it  may  easily  slip  off  and  be  swallowed  by 
the  patient,  an  accident  which  has  occasionally  occurred, 
though  without,  so  far  as  is  known,  any  serious  con- 
sequences. A  rubber  tube  is  probably  in  time  decom- 
posed or  dissolved  by  the  gastric  fluids,  and  gives  no 
permanent  inconvenience,  but  the  accident  is  not  a 
desirable  one  nevertheless.  Besides  milk  and  eggs, 
other  fluids  may  be  used — broths,  thin  gruels,  or  what- 
ever is  thought  desirable  that  is  capable  of  being  passed 
through  the  feeding-tube.  One  advantage  of  the  oral 
tube  not  before  mentioned  is  that  with  its  larger 
caliber  fluids  or  semi-fluids  of  greater  consistence  can 
be  used,  whereas  with  the  nasal  tube  only  those  which 
flow  readily  through  a  small  aperture  can  be  employed. 

Forced  feeding  is  best  given  to  the  patient  in  the 


ARTIFICIAL    FEEDING.  115 

recumbent  position,  and  in  this  way  he  can  be  secured 
by  a  sheet  or  blanket  passed  over  his  body  up  to  the 
neck,  with  an  attendant  sitting  on  the  edge.  With 
those,  however,  who  are  accustomed  to  this  form  of 
feeding,  and  who  do  not  resist,  it  matters  little  in  what 
position  it  is  accomplished.  The  tube  in  all  cases 
should  be  slightly  lubricated,  and  the  diet  fluid  itself 
will  often  answer  for  this  purpose. 

While  the  first  attempts  at  feeding  are  apt  to  be 
very  disagreeable,  and  are  in  many  cases,  for  this 
reason,  sufficient  to  induce  the  patient  to  return  to 
taking  his  nourishment  in  a  natural  way,  yet  the 
pharynx  soon  loses  its  hypersensibility,  and  in  many 
cases  of  obstinate  refusal  of  food  the  operation  becomes 
such  an  easy  one  that  it  can  be  attended  to  by  an  ordi- 
nary attendant.  The  patients  in  these  cases  voluntarily 
swallow  the  tube,  and  the  danger  of  its  entering  the 
larynx  is  thus  avoided.  It  is  advisable,  however,  on 
account  of  the  possibility  of  accident,  that  the  forced 
feeding  should  always  be  administered  by  the  physician, 
or  at  least  under  his  direct  supervision.  It  is  only  in 
these  cases  of  long-continued  feeding,  where  it  has 
become  almost  a  second  nature  to  the  patient,  and  in 
which  he  possibly  cooperates,  that  it  is  at  all  safe  to 
have  it  done  out  of  the  physician's  sight.  This  point 
is  an  important  one. 

The  forced  feeding  may  sometimes  be  required  to  be 
continued  for  a  long  period — six  and  even  nine  years 
of  this  treatment  have  been  reported  in  special  cases. 
It  is  rarely,  however,  in  acute  insanity  that  it  has  to 
be  kept  up  more  than  a  few  days,  or  a  week  at  the 
most,  and  there  should  be  a  constant  effort  made  to 
induce  the  patient  to  take  his  food  in  a  more  natural 
way.  Sometimes  only  one  or  two  applications  are 
necessary,  and  other  times,  with  constant  trials,  success 
will  be  attained  in  a  few  days  or  weeks.  After  the 
patient  has  once  gotten  to  eating  by  himself,  or  from 


Il6  GENERAL    THERAPEUTICS. 

the  hand  of  an  attendant,  it  is  seldom  necessary  to  re- 
turn to  the  use  of  the  tube. 

The  question  as  to  how  long  the  patient  should  be 
allowed  to  go  without  eating  or  forced  feeding  is  to 
be  answered  according  to  his  condition.  If  well 
nourished,  active,  or  not  seriously  or  rapidly  deteriorat- 
ing in  his  physical  state,  even  a  week  may  be  allowed 
to  elapse  sometimes.  It  is  a  more  serious  mistake, 
however,  to  postpone  artificial  alimentation  too  long 
than  to  begin  it  too  early.  Generally,  after  three  or 
four  days  of  abstinence,  it  is  perfectly  justifiable  to 
have  recourse  to  the  stomach-  or  nasal  tube,  both  for 
the  actual  effect  on  the  patient's  physical  condition, 
and,  in  many  cases,  for  the  moral  effect,  which  is  alone 
often  sufficient  to  induce  him  to  return  to  eating.  In 
cases  of  paranoia,  where  the  refusal  of  food  is  due  to 
delusions,  it  is  not  often  necessary  to  have  recourse  to 
artificial  alimentation.  In  some  hysteric  cases  the 
patient  will  refuse  food,  but  if  allowed  to  take  it 
surreptitiously,  will  eat  an  ample  allowance.  All 
insane  cases  require  to  be  carefully  watched  and  studied 
as  to  their  peculiarities  in  these  respects,  and  their 
management  varies  accordingly. 

One  of  the  most  important  matters  in  any  case  of 
acute  insanity  is  to  watch  and  regulate  the  excretion. 
The  urine  may  be  suppressed  or  may  be  retained  from 
pure  mental  inertia  in  some  depressed  cases,  and  its 
examination  here,  as  in  other  morbid  states,  is  of  the 
highest  importance  as  indicating  the  state  of  toxin 
excretion,  etc.,  and  as  a  possible  guide  to  the  detection 
of  serious  disease  of  important  organs.  As  regards  the 
immediate  treatment,  however,  the  alvine  excretions 
are  of  still  more  importance.  It  is  so  common  as  to 
be  the  rule  in  acute  insanity  to  find  a  sluggish  condition 
of  the  bowels,  and  in  the  curable  forms  of  depressive 
derangement  and  confusional  insanity  this  is  par- 
ticularly the  case.     In  some  of  these  neglected  patients 


ATTENTION    TO    THE    EXCRETIONS.  117 

we  find  almost  complete  obstruction,  and  we  have 
seen  a  case  where  long  and  tedious  mining  operations, 
so  to  speak,  were  required  to  remove  the  mass  of  im- 
pacted feces  in  the  rectum  and  lower  boweL  Some- 
times there  appears  to  be  a  sort  of  intestinal  paraly- 
sis, and  it  is  quite  a  while  before  the  normal  action  of 
the  bowels  can  be  reinstated.  It  is  well  to  look  after 
this  function  in  the  very  earliest  treatment,  and  in 
nearly  every  case  where  it  is  practicable — and  with 
suitable  attendance  this  includes  nearly  all — to  give 
an  enema  the  first  thing.  The  effect  of  this,  combined 
with  a  warm  bath  and  proper  feeding,  is  sometimes 
most  striking;  recovery  may  date  its  beginning  from 
this  point.  The  mere  unloading  of  the  clogged  and 
distended  bowel  has  often  itself  a  most  happy  effect  to 
all  appearance,  and  it  seems  probable  that  we  cannot 
altogether  reject  the  agency  of  a  reflex  action  on 
the  brain  in  these  cases.  We  all  know  something  of 
the  feeling  of  relief  when  a  costive  condition  is  over- 
come, and  part  of  this  may  be  due  to  the  removal  of  a 
mechanical  clogging  of  the  prima  via;  and  it  is  not 
hard  to  assume  that  an  excessive  aggravation  of  this 
common  irritation  from  costiveness  may  have  a  decided 
influence  in  the  causation  or  continuance  of  a  state 
of  mental  aberration.  It  is  probable,  however,  that 
the  modern  notions  of  auto-intoxication  have  their 
application  here,  and  that  the  condition  may  be  largely 
influenced  by  the  retention  of  toxic  products  with  a 
sort  of  continuous  absorption  that  is  at  once  relieved 
by  the  evacuation  and  thorough  cleansing  of  the  lower 
bowel.  As  a  practical  fact,  this  matter  of  attention 
to  the  condition  of  the  bowels  is  one  of  the  most  im- 
portant of  all  in  the  treatment  of  insanity,  and  much 
will  have  to  be  said  of  it  when  speaking  of  the  special 
therapeutics  of  the  different  forms  of  mental  disease. 
It  is  a  point,  moreover,  that  has  been  to  some  extent 
neglected    or    not    sufficiently    emphasized    by    some 


115  GENERAL    THERAPEUTICS. 

writers,  and  we  therefore  wish  to  call  more  particular 
attention  to  it  here. 

It  is  not  generally  advisable  to  use  the  more  severely- 
acting  cathartics  for  the  constipation  of  the  insane; 
as  a  rule,  the  bowels  are  easily  kept  open  after  an 
enema  has  cleared  out  the  rectum,  by  the  cascara 
preparations  or  similar  mild  and  unirritating  laxatives. 
In  some  cases  where  the  whole  digestive  tract  is  badly 
involved,  as  shown  by  a  heavily  coated  tongue  and  a 
very  torpid  state  of  the  bowel,  small  doses  of  calomel 
frequently  repeated,  -^  of  a  grain  every  hour  or  half 
hour  till  eight  or  ten  doses  have  been  given,  will  be 
effective  when  other  means  fail.  All  that  is  wanted 
in  any  case  is  to  have  a  free  normal  action,  and  after 
this  has  once  been  started  there  is  usually  not  much 
difficult}'  in  keeping  it  up.  One  point,  however,  must 
be  attended  to — the  prrysician  must  satisfy  himself 
that  there  is  normal  excretion.  We  have  seen  patients 
apparently  regular  in  going  to  stool,  who  were  never- 
theless suffering  from  fecal  accumulation;  they  were 
merely  passing  off  small  quantities  at  a  time,  while  the 
masses  were  piling  up  in  the  rectum.  An  occasional 
colonic  flushing  with  the  normal  saline  solution,  if  the 
discharge  is  at  all  insufficient  or  if  the  patient's  general 
symptoms  suggest  any  intestinal  intoxication  or  reflex 
irritation  from  this  source,  is  often  followed  by  marked 
general  improvement  for  the  time. 

In  mania  and  in  some  other  conditions  the  bowels 
may  be  loose;  but  this  symptom  is  to  be  met  as  the 
circumstances  demand. 

With  the  intestinal  disorder  the  gastric  functions  are 
often  more  or  less  disturbed,  and  in  certain  cases  call 
for  treatment.  In  acute  insanity  it  is  not  alwa)^s 
practicable  to  use  all  the  modern  diagnostic  methods 
for  stomach  disorder,  and  fortunately  they  are  usually 
not  necessary.  It  may  often  happen,  however,  that  a 
careful  study  of  the  gastric  condition  will  be  of  advan- 


EXERCISE    AND    EMPLOYMENT.  119 

tage  and  a  valuable  guide  to  treatment.  The  use  of 
gastric  and  intestinal  antiseptics,  especially  the  latter, 
may  be  indicated  in  some  of  these  cases  with  pronounced 
derangement  in  the  gastro-intestinal  tract.  Any  possi- 
ble complication  or  cause  that  may  exist  in  any  of  the 
bodily  organs  should  be  watched  for,  and  if  need  be, 
receive  due  attention.  Hence  the  value  of  thorough 
examination  in  all  cases,  especially  of  recent  or  acute 
mental  disease. 

When  the  patient  is  capable  of  taking  exercise,  it  is 
often  well  to  so  direct  his  activities  that  it  may  be  in  the 
direct  line  of  his  treatment.  It  has  been  long  observed 
in  asylums  that  when  patients  can  be  kept  out-of-doors 
for  a  considerable  part  of  the  day  they  are  generally 
much  quieter  and  more  tractable,  especially  at  night, 
when  their  disturbance  is  apt  to  be  more  troublesome 
under  other  conditions.  In  the  same  way,  with  acute 
cases  it  is  sometimes  well  to  give  them  special  care, 
and  keep  them  out-of-doors  to  work  off  their  activities 
by  walking,  or,  if  possible,  by  some  light  employment 
not  beyond  their  strength,  instead  of  allowing  them  to 
exert  themselves  unsystematically  and  uselessly  in 
their  own  way.  For  chronic  cases  employment  is 
almost  a  necessity,  and  absolutely  so  where  there  is 
no  physical  reason  to  contraindicate  it.  It  helps  the 
patient  to  forget  his  insane  fancies  or  delusions,  and, 
as  far  as  anything  can,  aids  in  his  mental  improvement. 
The  vicious  sexual  habits  of  patients  are  best  remedied 
and  counteracted  by  outdoor  work  carried  to  the  limit 
of  exhaustion,  so  that  rest  and  sleep  are  secured  for  the 
whole  period  necessary  for  reparation. 

While  it  is  not  always  desirable,  and  perhaps  not 
often  so,  to  entirely  check  the  activities  in  the  very 
acutely  maniacal  cases,  where  the  physical  condition  is 
good,  the  case  is  somewhat  different  with  those  cases 
where  exhaustion  is  one  of  the  factors  in  the  causation 
of  the  insanity,  and  a  somewhat  physically  deterior- 


120  GENERAL    THERAPEUTICS. 

ated  condition  is  a  prominent  feature.  Also,  in  a  large 
number  of  cases  of  depressive  insanity,  rest  and  quiet 
are  valuable  adjuncts  to  the  cure.  A  method  of  treat- 
ment that  has  been  in  vogue  for  the  last  few  years 
supplies  these  requisites,  and  is  especially  adapted  to 
the  treatment  of  cases  at  their  homes.  The  method 
consists  simply  in  putting  the  patient  to  bed  and 
keeping  him  there  during  the  early  acute  stages  of  his 
disease,  and  with  it  all  the  essentials  of  the  Weir 
Mitchell  rest  cure,  and  its  practice,  when  carried  out, 
has  without  question  been  of  advantage  to  a  great 
many  cases. 

The  results  of  this  treatment  are  very  generally 
good,  and  it  is  found  practicable  not  only  in  the 
weakened,  but  in  physically  strong  insane  individuals. 
The  moral  effect  is  undoubtedly  a  prominent  factor  in 
its  efficiency,  but  for  the  weakened  and  exhausted 
cases  the  systematic  feeding,  and,  in  some  instances,  the 
massage,  could  hardly  be  otherwise  than  beneficial. 
As  a  routine  treatment  for  all  classes  of  cases  it  can 
hardly  be  recommended,  and  it  comes,  in  some  of  its 
features,  very  close  to  the  discredited  methods  of 
restraint.  For  the  home  and  general  hospital  treat- 
ment of  insanity,  however,  whether  agitated  or  other- 
wise, it  will  be  found  often  extremely  convenient,  and 
will  resolve  certain  problems  that  would  otherwise 
puzzle  the  practitioner.  The  statistics  of  this  method, 
as  they  have  been  published  abroad,  do  not  show  that 
its  results  as  regards  cure  are  especially  better  than 
those  of  other  methods  formerly,  and  still  to  a  large 
extent,  employed.  It  has,  however,  the  advantage 
of  keeping  the  patient  quiet,  avoiding  destructiveness 
and  untidiness, — that  is,  provided  that  the  nurses  are 
efficient  and  understand  their  business, — and,  there- 
fore, in  an  asylum  it  may  be  said  to  meet  pretty  nearly 
the  same  indications  that  did  the  old-fashioned  methods 
of  physical  restraint,  but  in  a  less  objectionable  manner. 


RESTRAINT  AND  SECLUSION.  121 

Its  disadvantages  are  the  expense,  trained  nurses  being 
required  day  and  night  in  attendance,  with  additional 
help  at  hand  in  case  the  patient  becomes  too  obstreper- ' 
ous  to  be  easily  handled  by  them. 

Speaking  of  restraint,  it  may  be  said  that  it  has 
almost  gone  out  of  use,  in  the  general  acceptation  of 
the  word,  in  the  better-managed  hospitals  for  the 
insane.  The  camisole  or  strait -jacket,  the  muff,  the 
wristlets,  the  mittens,  the  anklets,  the  bed-straps,  and 
the  crib  are  nowadays  rarely  met  with,  and  only  ex- 
ceptionally used.  It  has  been  found  that  the  advan- 
tages of  any  extensive  use  of  these  apparatuses  are  far 
more  than  counterbalanced  by  their  disadvantages, 
both  to  the  patient  and  the  morale  of  the  institution. 
In  certain  surgical  cases,  however,  where  it  is  necessary 
to  retain  dressings  on  an  agitated  patient,  the  use  of 
some  sort  of  restraint  is  often  absolutely  necessary, 
and  there  are  other  rare  cases  of  extreme  violence  in 
crowded  establishments  where  they  will  also  be  re- 
quired. They  have  also,  in  rare  instances,  a  certain 
therapeutic  value  which  cannot  be  altogether  ignored, 
and  any  wholesale  condemnation  of  their  use  is  un- 
scientific. In  the  home  treatment  of  the  insane  they 
may  be  more  needed  under  certain  conditions,  and 
their  use  more  excusable,  than  in  asylums,  but 
they  should  be  avoided  as  far  as  possible.  The 
mittens  fastened  on  the  hands  without  restricting 
the  freedom  of  movement  of  the  arms,  or  the  wristlets 
and  anklets,  are  mild  forms  of  restraint  that  are  some- 
times of  advantage  with  very  destructive  patients, 
and  are  hardly  reckoned  as  objectionable  forms  by 
many  alienists. 

The  shutting-up  of  the  patient  alone  in  a  cell  or 
room,  padded,  darkened,  window-guarded,  or  other- 
wise, forms  the  so-called  seclusion,  which  is  generally 
classified  with  restraint,  and  comes  under  the  same 
general  condemnation.     It  has,   however,  its  uses  in 


122  GENERAL    THERAPEUTICS. 

many  cases,  and  for  therapeutic  purposes  cannot  be 
altogether  dispensed  with.  Many  patients  would 
voluntarily  prefer  seclusion  to  mingling  with  their 
fellows  in  the  asylum  ward,  and  this  may  be  occa- 
sionally to  their  advantage,  as  well  as  more  generally 
to  their  disadvantage.  The  great  objections  to  seclu- 
sion, when  much  practised,  are  that  it  takes  the 
patient  out  from  observation  of  the  attendant,  it  may 
lead  to  vicious  habits,  and  it  is  a  very  easily  abused 
method,  the  tendency  to  employ  it  unduly  being  very 
strong.  Neither  restraint  nor  seclusion  should  be  used 
except  under  the  advice  and  general  oversight  of  the 
physician,  and  this  is  as  true  in  the  care  of  the  insane 
at  their  homes  as  in  a  public  institution.  For  cases 
who  are  inclined  to  brood  over  their  condition,  and  to 
whom  the  stimulus  of  association  with  others  is  advis- 
able, seclusion  should  be  used,  if  at  all,  with  the  greatest 
caution. 

A  method  of  restraint  that  was  formerly  much  in 
use,  and  which  has  certain  therapeutic  advantages  in 
some  cases,  is  that  form  of  hydrotherapy  known  as  the 
cold-pack.  It  is  hardly  necessary  to  describe  the 
method  here,  as  it  is  well  known.  It  should  never  be 
used  simply  for  purposes  of  restraint;  its  utility  in 
insanity  is  entirely  in  its  hydrotherapeutic  application. 
We  have  already  spoken  of  baths  and  cold  effusions  in 
excited  conditions,  but  baths  are  also  useful  otherwise. 
A  warm  bath  at  bedtime  is  often  one  of  the  best 
incitants  to  sleep,  and  the  use  of  baths  generally  in 
insanity  has  been  highly  recommended,  especially  the 
Turkish  bath. 

Massage  is  a  measure  which  has  much  to  recommend 
it  in  certain  special  neurasthenic  and  depressed  con- 
ditions. 

Electricity  is  an  agent  which  has  been  recommended 
in  insanity,  as  in  almost  every  other  affection,  but  its 
uses  are  also  limited.     The  forms  under  which  it  may 


SPECIAL    MEASURES.  123 

be  said  to  have  the  best  effect  are  general  faradi- 
zation, static  electricity  by  insulation,  and  cerebral 
galvanization.  The  uses  of  electricity  for  cases  of 
paralysis,  where  not  specially  contraindicated  by  the 
mental  condition  of  the  patient,  are  the  same  as  in  the 
mentally  sound. 

Hypnotism  has  been  tried,  and  some  have  spoken  of 
success  with  its  use.  As  a  general  thing,  however,  it 
will  be  found  that  the  insane  do  not  make  good  hyp- 
notic subjects,  and  that  its  utility  is  very  restricted 
in  most  forms  of  mental  disease.  In  some  hysteric 
cases  it  may  be  of  use,  but  there  are  some  difficulties 
even  there.  It  cannot  be  regarded,  in  our  opinion,  as 
an  efficient  therapeutic  agent  in  the  general  treatment 
of  insanity.  When  it  is  found  useful,  the  case  is  ex- 
ceptional. It  should  be  remembered,  also,  that  the 
induction  of  hypnotism  is  the  production  of  a  morbid 
condition  in  the  brain,  and  that  there  is  sometimes  a 
risk  in  its  use. 

Certain  special  features  of  insanity  require  special 
measures  for  their  relief.  One  of  these  which  has  very 
important  practical  bearing  is  the  general  untidiness 
and  filthy  habits  of  many  of  the  acute  and  chronic 
insane.  They  are  absolutely  neglectful  of  all  decency, 
and  sometimes  appear  to  be  perversely  inclined  to 
aggravate  their  care-takers  by  their  outrageous  filthi- 
ness.  The  personal  cleanliness  of  the  patient  is,  of 
course,  naturally  the  care  of  the  attending  nurse,  who 
will  find  her  strength  and  wits  often  severely  taxed  to 
meet  the  needs  of  the  case.  For  patients  that 
are  simply  untidy,  close  attention  to  the  condition 
of  the  excretions  will  sometimes  suffice.  For  those 
that  are  more  actively  and  viciously  filthy,  other 
measures  may  be  necessary.  In  some  cases  where 
patients  have  habits  of  defiling  their  rooms,  bedding, 
and  so  forth,  at  night,  a  thorough  injection  of  salt  and 
water  several  hours  before  bedtime,  with  consequent 


124  GENERAL    THERAPEUTICS. 

complete  cleaning  out  of  the  large  intestine,  will  have 
a  very  excellent  effect.  This  will  have  to  be  done, 
generally,  by  force,  and  should  be  carried  out  under 
the  eye  of  some  responsible  person — the  physician,  if 
possible.  It  sometimes  seems  to  have  not  only  a 
mechanical  effect,  but  a  very  important  moral  effect 
upon  the  patient,  and  instances  of  recovery  apparently 
dating  from  this  treatment  have  been  known. 

The  destructive  habits  of  the  insane  are  well  known, 
and  they  were  formerly  checked  largely  by  the  use  of 
mechanical  restraint.  Much  can  be  done,  however,  to 
better  them  by  close  attention  on  the  part  of  the 
attendant,  and  by  giving  them  something  to  employ 
their  activities  in  a  more  harmless  way.  Patients  that 
simply  tear  their  clothes  can  have  their  hands  occupied 
with  some  simple  employment  easily  devised,  and  can 
sometimes  be  made  really  useful.  In  other  cases,  it 
is  customary  in  some  hospitals  to  use  bedding  and 
clothing  made  of  heavy  material,  which  is  not  easily 
destroyed.  A  certain  amount  of  destructiveness  and 
sacrifice  of  property  is  probably  unavoidable  in  many 
cases. 

A  tendency  to  suicide  can  be  guarded  against  only 
by  constant  watchfulness,  and  the  removal  of  all 
facilities  for  self-destruction  or  injury.  In  these  cases, 
as  in  the  destructive  and  untidy  ones,  almost  every- 
thing depends  upon  the  tact  and  skill  in  managing 
the  patient,  and  there  are  persons  who  seem  to  be  able 
to  avoid  all  these  accidents  to  the  patients  under  their 
charge.  The  vicious  sexual  habits,  masturbation,  etc., 
have  been  already  noted,  and  employment  mentioned 
as  their  best  antidote.  Something,  however,  may  be 
done  with  drugs,  bromids,  etc.,  and  with  regulated  diet. 
Other  measures,  such  as  blisters  and  so  forth,  have  only 
a  temporary  effect,  as  a  rule,  and  restraint  is  absolutely 
futile  in  determined  cases.  It  should  be  remembered 
that   these   practices   are   often   only   a    symptom   of 


SURGERY.  125 

insanity,  and  that  they  cease  with  the  mental  improve- 
ment. 

From  time  to  time  we  hear  of  cases  of  insanity  cured 
more  or  less  completely  by  surgical  operations,  and 
the  surgical  therapeutics  of  mental  disease  has  there- 
fore a  claim  for  consideration.  Some  of  the  cases 
reported  are  undoubtedly  only  temporary  ameliora- 
tion; others  may  be  actual  cures,  or  very  noticeable 
improvement.  Even  in  some  pronounced  degenerative 
types,  surgical  measures,  or  what  amount  to  the  same 
thing,  have  been  reported  as  curative,  though  the 
credit  given  them  is  doubtless  in  many  cases  exag- 
gerated. Lannelongue's  operation  for  idiocy  is  in 
point ;  there  may  be  a  few  cases  where  constriction  of 
the  brain  occurs  which  can  be  relieved  by  craniectomy, 
but  such  instances  must  be  few  and  far  between. 
We  have  ourselves  known  a  case  of  periodic  moral 
insanity  apparently  cured  by  a  severe  injury,  and  it 
is  possible  that  there  are  many  instances  falling  more 
or  less  fully  into  this  class.  In  cases  of  traumatic 
insanity,  especially  where  there  has  been  neglected 
depression  of  the  cranial  bone,  surgery  is,  of  course, 
indicated,  and  may  be  expected  to  be  beneficial  in  its 
effects.  Aside  from  these,  however,  its  utility  is 
slight,  and  the  surgical  therapeutics  of  insanity  may 
be  considered  as  very  limited  in  their  scope,  however 
remarkable  the  cures  sometimes  reported.  With 
modern  antiseptic  methods  surgery  of  the  brain  is 
certainly  safer  than  it  formerly  was,  and  many  opera- 
tions that  were  formerly  dangerous,  and  therefore 
unjustifiable,  may  now,  perhaps,  be  attempted,  even 
with  a  remote  chance  of  their  doing  good. 

Some  authorities  (Rohe,  Hobbs,  Holt)  have  claimed 
very  striking  cures  from  gynecologic  operations  on  the 
insane,  and  have  insisted  that  neglected  disorders  of 
the  female  genital  apparatus  are  responsible  for  a  very 
large  proportion  of  the  cases  of  insanity  in  women. 


126  GENERAL    THERAPEUTICS. 

What  has  been  said  as  to  searching  out  every  bodily- 
cause  that  may  have  any  possible  relation  to  the 
mental  disorder  applies  here,  and  there  is  no  ques- 
tion that  an  insane  woman  has  the  same  right  to  be 
relieved  of  her  physical  infirmities  as  a  sane  one.  It 
is  well,  however,  not  to  be  too  sanguine  as  to  permanent 
results  as  regards  the  mental  condition  from  such 
operations.  The  facts  given  by  the  advocates  of  this 
procedure  of  generally  operating  for  the  gynecologic 
disorders  in  the  insane  are  not  absolutely  conclusive; 
many  of  their  best  successes  were  obtained  with  com- 
paratively recent  and  presumably  curable  cases,  and 
others  have  not  fully  stood  the  test  of  time  or  their 
after-history  has  not  been  fully  given.  In  many 
chronic  cases  a  severe  illness  or  operation  may  easily 
produce  a  temporary  betterment;  we  have  seen  an 
apparently  completely  demented  woman  become  com- 
paratively lucid  in  severe  bodily  disease.  Only  long- 
continued  observation  can  supply  adequate  proof  of  the 
value  of  such  operations,  and,  so  far  as  we  have  this 
in  the  experience  of  the  mass  of  alienist  physicians, 
even  those  who  are  by  no  means  negligent  in  such 
matters,  it  has  not  been  forthcoming.  It  is  best, 
therefore,  to  reserve  opinions  as  to  such  measures,  and 
where  they  are  not  clearly  necessitated  for  the  patient's 
physical  welfare,  there  may  often  be  a  doubt  as  to  their 
propriety  in  the  insane  woman  in  her  irresponsible 
mental  condition. 

In  any  case  a  judicious  conservatism  is  better  than 
a  too  radical  operative  enthusiasm,  and  as  the  case 
stands  there  is  a  reasonable  doubt  as  to  the  value  of 
any  such  wholesale  measures  as  some  have  advocated. 
In  private  practice  amongst  friends  and  relatives  of 
the  patient,  gynecologic  operations,  it  must  be  said, 
can  sometimes  be  performed  without  the  embarrass- 
ments attending  them  in  public  hospitals  for  the 
insane,  where  the  patient  herself  cannot  be  a  legally 


MORAL    TREATMENT.  I  27 

consenting  party  and  the  guardians  and  friends  are 
inaccessible,  hostile,  or  suspicious. 

Serum  and  organ  therapy  have  as  yet  no  standing  in 
the  treatment  of  mental  disease,  with  the  one  brilliant 
exception  of  the  thyroid  treatment  in  myxedematous 
idiocy,  where  it  comes  near  to  being  a  specific.  Thy- 
roids have  been  tried  in  other  forms  of  insanity  (Bruce 
and  McPhail,  Mabon,  Babcock,  Berkley,  Middlemass), 
and  good  results  have  been  reported  by  some.  The 
treatment  appears  to  decidedly  affect  metabolism,  and 
we  have  seen  it  apparently  of  value  in  one  or  two  cases 
where  there  appeared  to  be  a  possible  thyroid  defect. 
In  the  average  of  cases,  however,  its  action  cannot  be 
usually  foretold  and  its  use  is  empiric.  Properly  given, 
in  suitable  cases,  and  watched,  it  can  do  no  serious 
harm,  and  its  trial  may  often  be  warranted  as  a  justi- 
fiable experiment  for  the  patient's  good. 

The  moral  or  psychic  treatment  of  mental  disorders 
comprises  the  whole  range  of  methods  and  devices  that 
can  affect  the  patient's  condition  otherwise  than 
through  the  ordinary  medicinal  and  mechanical  means 
employed.  The  general  principles  are  few,  and  the 
first  of  these  in  importance  is  that  the  physician,  and 
whoever  else  may  have  the  direct  care  of  the  insane, 
should  govern  themselves  according  to  the  rules  of 
strict  honesty  and  fairness  in  all  their  dealings.  The 
question  sometimes  arises  whether  it  is  justifiable,  or 
even  expedient,  in  any  case  to  deceive  the  patient. 
That  this  is  habitually  done  by  outsiders  does  not 
affect  the  question.  Those  who  have  to  deal  with  the 
patient  for  any  length  of  time  will  find  it  almost,  if  not 
absolutely,  an  invariable  rule  that  it  is  best  to  impress 
upon  their  charges  the  perfect  reliability  of  those  that 
have  to  do  with  them.  If  it  is  possible,  as  it  generally 
is,  to  treat  the  patient  as  a  sick  man,  realizing  his  own 
condition  and  wishing  to  cooperate  in  the  measures 
taken  for  his  relief,  it  is  best  to  do  so ;  the  more  nearly 


128  GENERAL    THERAPEUTICS. 

we  can  treat  them  as  rational  beings,  the  better,  as  a 
rule,  will  we  succeed  with  the  insane.  Allusion  has 
already  been  made  to  this  fact,  but  it  cannot  be  too 
much  emphasized.  Anything  like  active  deception,  on 
the  other  hand,  is  likely  to  react  disastrously  upon  the 
person  availing  himself  of  it.  If  we  cannot  get  the 
full  confidence  of  our  patients,  we  should  at  least 
endeavor  to  give  them  no  reason  for  distrusting  us. 

A  second  general  principle  of  the  moral  treatment  of 
insanity,  and  this  is  a  very  general  one,  is  that  every 
case  is  a  study  by  itself,  and  the  measures  taken  should 
be  adapted  to  its  special  needs.  No  one  has  better 
reason  to  make  a  study  of  character  than  the  physician 
in  charge  of  the  insane,  and  his  conduct  toward  them 
will  be  modified,  advantageously  or  otherwise,  accord- 
ing to  his  skill  in  estimating  human  nature  and  indi- 
vidual peculiarities  as  they  appear  in  persons  suffering 
from  diseases  of  the  mind.  What  would  be  useful  to 
one  patient  would  be  damaging  to  another,  and  it  is 
sometimes  hard  to  distinguish  which  of  these  results 
is  going  to  follow  any  particular  course  of  conduct. 
For  this  reason,  therefore,  the  first  general  principle 
comes  always  into  play.  There  should  be  good  inten- 
tions and  absolute  rectitude  of  conduct  in  carrying  out 
whatever  measures  are  adopted;  these  are  essential. 
Following  these  two  general  principles,  the  moral  treat- 
ment will  be  at  least  the  best  that  is  in  the  capacity 
of  its  director.  Not  every  one  has  equal  address  and 
tact  in  managing  the  insane,  but  no  amount  of  skill 
will  compensate  for  unreliability  of  purpose  or  conduct. 

In  large  asylums  much  can  be  done  in  the  way  of 
change  of  wards  and  associations  with  other  and 
different  classes  of  patients  in  the  way  of  moral  treat- 
ment of  the  insane.  It  often  happens  that  certain 
patients,  though  not  recovered  themselves,  have  an 
excellent  influence  over  certain  other  patients,  and  a 
proper  realization   of  this  fact   is   sometimes   a  very 


MORAL    TREATMENT.  129 

valuable  aid  in  the  treatment  of  cases  in  certain  stages 
of  their  mental  disorder.  This  resource  is,  of  course, 
not  available  to  such  an  extent  in  small  institutions, 
or  in  the  home  care  of  the  insane,  and  it  is  one  of  the 
disadvantages  of  both  of  these  that  such  is  the  case. 
In  the  large  institutions,  also,  there  is  a  greater  diversity 
of  employment,  more  distractions  and  diversions 
which  can  be  carried  on  under  the  direct  supervision  of 
the  medical  officers,  and,  in  certain  classes  of  cases, 
greatly  to  their  benefit. 

It  is  hardly  necessary  to  state  that  anything  like 
actual  intimidation  or  punishment  should  form  no 
part  of  the  moral  treatment ;  what  disciplinary  meas- 
ures are  required  should  be  also  justified  by  the 
medical  necessities  and  therapeutics  of  the  case. 
Removal  from  one  ward  to  another,  according  to 
the  patient's  condition,  will  often  be  appreciated  by 
the  patient,  to  some  extent,  as  discipline,  though  it 
is  necessitated  by  his  conduct  or  his  physical  and 
mental  condition.  The  same  is  true  of  the  necessary 
cutting  off  of  certain  privileges,  where  they  are  abused 
or  not  appreciated,  and  these  two  classes  of  measures 
are  found  quite  sufficient  for  all  needs  of  discipline  in 
large  institutions.  It  should  also  be  unnecessary  to 
say  that  the  physicians,  attendants,  and  whoever  else 
comes  in  direct  contact  with  the  unfortunate  of  these 
classes,  should  have  thorough  self-control,  ample 
patience,  and  ready  ability  to  turn  whatever  may 
happen  to  the  best  account.  There  should  be  a  feeling 
on  the  part  of  all  of  them  that  they  are  dealing  with 
irresponsible  persons,  and  whatever  insults  or  injuries 
they  may  receive  are  not  to  be  taken  as  coming  from 
any  one  against  whom  any  resentment  could  properly 
be  felt.  The  possession  of  mental  health  among  these 
unfortunates  who  are  deprived  of  it  should  incite  a 
feeling  of  a  sort  of  noblesse  oblige,  which  ought  to 
make  any  provocation  or  annoyance  experienced  to  be 


130  GENERAL    THERAPEUTICS. 

felt  as  a  matter  of  no  particular  importance.  This, 
of  course,  does  not  imply  that  any  undue  feeling  of 
personal  superiority,  or  of  disparagement  of  those  who 
suffer  from  the  evil  of  insanity,  should  be  encouraged 
or  kept  up. 

In  the  early  stages  of  very  acute  insanity,  such  as 
maniacal  frenzy,  extremely  agitated  melancholia,  or 
any  pronounced  motor  and  emotional  disturbances,  the 
value  of  moral  treatment  is  hardly  perceptible;  but 
even  in  these,  transfer  to  the  asylum,  which  constitutes 
a  form  of  suggestive  therapeutics,  has  often  a  most 
beneficial  effect.  It  is  common  to  see  a  patient  who 
has  been  almost  continuously  agitated  and  noisy 
brought  in  in  restraint  apparatus,  which  are  immedi- 
ately removed,  and  he  sits  quiet  and  composedly  in 
the  ward  where  he  is  placed.  There  is,  we  might  say, 
a  sort  of  atmosphere  of  discipline  and  control  about 
the  place  which  is  immediately  appreciated  often  by 
the  wildest  patients.  In  later  stages  of  the  disease, 
however,  and  especially  toward  convalescence,  and  at 
the  turning-point  between  chronicity  and  recovery,  the 
moral  treatment  is  of  the  utmost  value.  The  prin- 
cipal idea  will  be,  in  most  cases,  to  keep  from  the 
patient  every  possible  irritation  or  other  cause  of  a 
relapse;  unpleasant  news  from  home,  injudiciously 
timed  visits,  or  those  by  persons  who  have  not  the  tact 
or  judgment  to  refrain  from  saying  or  doing  things 
that  can  disturb  the  patient's  mental  equilibrium, 
ought  to  be  most  carefully  avoided,  and  even  the 
reception  of  letters  is  a  matter  for  the  physician's  care- 
ful oversight.  The  chance  of  these  things  doing  harm 
is  in  most  cases  comparatively  small,  but  there  are 
occasions  when  the  exercise  of  correct  judgment  in 
these  matters  is  of  the  utmost  importance  for  the 
patient's  welfare. 

In  delusional  cases  it  is  customary  to  say  that  any 
contradiction  or  argument  against  these  false  notions 


MORAL    TREATMENT.  131 

is  to  be  carefully  avoided.  This  is  true,  as  a  general 
rule,  and  especially  so  in  certain  phases  of  the  disorder. 
Here,  however,  as  in  everything  else  in  the  treatment 
of  insanity,  a  careful  study  of  each  individual  case  is 
absolutely  necessary,  and  there  are  times  when  even 
delusions  may  be  judiciously  combated.  It  is  often  a 
serious  question  just  how  we  are  to  treat  this  symptom, 
as  anything  we  may  do  may  have  untoward  effects. 
The  general  rule  will  be  that  while  they  should  not  be 
contradicted,  they  should  not  be  acquiesced  in,  and 
here  the  tact  of  the  physician  and  the  attendant  will 
have  full  sway.  The  best  plan  probably  is  to  have  at 
least  an  understanding  with  the  patient  that  he  is  con- 
sidered an  invalid  as  regards  his  mind,  and  is  treated 
as  such  with  the  utmost  consideration.  With  some 
patients  the  feeling  that  this  is  the  case  will  be  an 
aggravation,  but  these  are  in  the  minority,  and  most 
will  appreciate  kindness  and  courtesy  that  are  shown 
them  under  such  conditions,  even  though  they  may 
persistently  demand  recognition  of  their  delusions. 

The  moral  treatment  of  the  chronic  insane  differs  but 
little  from  that  of  the  curable  cases  in  the  stages  where 
it  is  available.  As  a  rule  they  are  more  amenable  to 
moral  treatment,  which  must  necessarily  comprise  the 
greater  part  of  the  therapeutics  of  their  disorder.  With 
a  certain  class  of  patients,  like  many  epileptics,  who 
are  absolutely  rational  for  a  large  part  of  the  time, 
much  can  be  done  in  the  way  of  getting  their  active 
cooperation  in  the  measures  required  for  their  control. 
A  good  set  of  rules,  reasonable  and  yet  strict,  fairly 
stated  to  them,  with  the  reasons  for  their  adoption,  will 
very  generally  be  accepted,  and  whatever  special  privi- 
leges are  given  in  the  way  of  exceptions  to  these  rules,  if 
properly  understood  as  favors,  and  not  as  rights,  will 
be  gratefully  received.  If,  on  the  other  hand,  they 
are  given  indiscriminately,  so  that  the  patient  feels 
aggrieved  at  their  being  shut  off,  trouble  is  almost  sure 


132  GENERAL    THERAPEUTICS. 

to  follow.  The  management  of  these  cases  should  be 
with  a  firm  yet  gentle  hand- 
One  thing  should  be  remembered  in  the  treatment  of 
every  form  and  case  of  insanity ;  that  is,  to  look  out 
sharply  and  constantly  for  any  symptoms  of  change. 
The  insane  are  characteristically  unreliable,  and  even 
the  most  harmless  cases  may  sometimes  develop 
dangerous  or  unfortunate  tendencies.  On  the  other 
hand,  even  in  the  most  hopeless  appearing  cases,  a 
change  for  the  better  may  sometimes  occur,  and  if 
promptly  taken  advantage  of  may  end  in  at  least  a 
partial  recovery.  Cases  are  constantly  reported  in  the 
journals  of  recoveries  from  chronic  insanity  of  five,  ten, 
or  even  twenty  years'  duration.  While  these  are  rare, 
they  should  not  be  forgotten,  and  no  case,  where  there 
is  not  irreparable  and  demonstrable  organic  disease, 
fatally  affecting  the  mental  functions  of  the  brain, 
should  be  considered  as  absolutely  hopeless.  Even 
paresis,  which  is  considered  as  perhaps  the  most  hope- 
less form  of  mental  disorder,  and  the  most  inevitably 
fatal  within  a  few  years,  may  undergo  long  remissions, 
some  of  which  can  hardly  be  separated  from  actual 
recoveries. 


CHAPTER  IX. 
CLASSIFICATION. 

Some  sort  of  classification  of  the  different  forms  of 
insanity  is  a  necessary  prelude  to  their  description.  It 
has  been  customary  of  late  years  to  disparage  classi- 
fications of  mental  diseases,  and  to  say  that  the  simplest 
and  briefest  is  the  best.  This  fact  is  due  largely  to  the 
difficulty  of  making  any  uniform  systematic  arrange- 
ment that  is  accepted  by  or  acceptable  to  all  who  have 
written  on  the  subject.  Almost  every  author  of  a  work 
on  insanity  has  promulgated  his  own  classification, 
differing  more  or  less  widely  from  that  of  all  others. 
The  result  has  been  to  discredit,  in  a  measure,  all  such 
attempts.  It  is  nevertheless  the  fact  that  some  sort 
of  systematic  classification  is  absolutely  necessary,  and 
it  cannot  be  up  to  the  needs  of  our  knowledge  of  dis- 
orders of  the  mind  and  merely  include  the  simple  symp- 
tomatic forms  that  were  alone  represented  in  the  earlier 
classifications. 

A  classification  of  insanity  falls  usually  and  naturally 
into  one  of  three  groups:  the  symptomatic,  the  patho- 
logic, and  the  etiologic.  We  might  add,  also,  the 
psychologic,  of  which  a  few  examples  have  been  given  in 
times  past.  The  most  natural  and  readily  made  classi- 
fication is  the  symptomatic,  and  the  earlier  ones  were 
nearly  all  of  this  type.  It  is  easier  to  see  the  obvious 
distinction  based  on  symptoms  than  to  attempt  to 
divide  all  the  forms  of  mental  disorders  according  to 
any  supposed  pathologic  condition.  We  say  supposed, 
for  our  knowledge  of  the  pathology  of  insanity  is  yet 
too  little  advanced  to  enable  us  to  carry  even  the 
simplest  classification  entirely  on  this  one  standard. 

*33 


134  CLASSIFICATION. 

The  pathologic  classifications  which  have  been  at- 
tempted are  therefore  unsatisfactory,  because  they  are 
based  on  imperfect  knowledge,  and  their  inconsistencies 
are  too  obvious  to  render  them  acceptable.  An  etio- 
logic  classification  is  simple  enough,  but  that  is  about 
all  that  can  be  said  in  its  favor,  and  it  necessarily  fails 
where  the  history  of  the  case  is  lacking.  There  is  a 
certain  relation  often  between  the  cause  and  the  form 
of  the  disease,  but  this  is  not  constant,  and  the  excep- 
tions are  too  numerous  to  permit  any  positive  general 
rules.  One  has,  also,  in  following  this  plan,  to  include 
under  the  same  head  the  most  widely  differing  symp- 
tomatic forms,  a  course  which  is  too  unnatural  to  be 
desirable,  in  spite  of  the  convenience  of  referring  each 
case  to  a  species  based  upon  its  alleged  or  presumed 
causation. 

Most  classifications  of  insanity  which  have  been  made 
are  therefore  composite  productions,  based  on  no  one 
simple  plan.  They  are  partly  etiologic,  largely  symp- 
tomatic, and,  where  possible,  pathologic,  in  their 
general  idea  or  conception.  Occasionally  we  have  one 
that  follows  the  psychologic  plan,  like  the  following  of 
Ziehen.  It  will  be  seen  that  here  we  have  a  rather 
consistent  system,  based  upon  the  mental  states  alone : 

CLASSIFICATION  OF  TH.   ZIEHEN. 
/.   Psychoses  without  intelligence  defect. 

A.   Simple  psychoses  :  only  one  chief  phase. 

1.  Affective  psychoses  :  chief  symptoms  in  the  emotional  sphere. 

(a)  Mania. 

(b)  Melancholia. 

(c)  Neurasthenia. 

2.  Intellectual  psychoses :   chief  symptoms  in  the  region  of  the  intellect. 

(a)  Stupidity. 

(b)  Paranoia. 

(a)  Paranoia  simplex. 

(b)  Paranoia  hallucinatoria. 

(r)     Delirious  (Ideenfluechtige)  form. 

(d)  Stuporous  form. 

(e)  Incoherent  form. 

(c)  Insanity  of  fixed  ideas. 


ZIEHEN KRAEPELIN.  135 

B.  Combined  psychoses,  with  several  phases. 
2.  Defect  psychoses. 

A.  Congenital  mental  weakness. 

(a)  Idiocy. 

(b)  Imbecility. 

(c)  Debility. 

B.  Acquired  mental  weakness  or  dementia. 

(a)  Dementia  paralytica. 

(b)  Senile  dementia. 

(c)  Secondary  dementia  after  functional  psychoses. 

(d)  Secondary  dementia  with  local  brain  disease  (syphilis  cerebri,  etc.). 

(e)  Epileptic  dementia. 

(f )  Alcoholic  dementia. 

This  is  the  most  recent  classification  proposed  on  a 
purely  psychologic  basis.  It  has  the  advantage  of 
being  symptomatic  as  well,  and  is  probably  as  good  a 
type  of  a  special  systematic  arrangement  based  mainly 
or  entirely  on  mental  symptoms  as  has  been  proposed. 
It  also  is  consistent  throughout,  and  not  mixed,  partly 
pathologic,  partly  symptomatic. 

Another  German  classification  of  very  recent  date, 
and  one  that  has  some  special  features  of  interest, — 
for  example,  the  inclusion  of  the  usually  considered 
primary  insanities,  mania  and  melancholia,  in  the 
degenerative  periodic  forms, — is  that  of  Kraepelin.  It 
has,  as  will  be  seen,  a  sort  of  pathologico-etiologic 
basis,  one  which  seems  likely  to  come  into  favor  as 
probably  the  best  available  basis  with  our  present 
knowledge  of  the  actual  underlying  conditions  of 
mental  disease. 

CLASSIFICATION  OF  KRAEPELIN  (1897). 
A.  Acquired  insanities. 

I.    Exhaustive  conditions. 

a.  Collapse  delirium. 

b.  Acute  confusional  insanity  (Verwirrheit). 

c.  Acute  dementia. 

d.  Acute  nervous  exhaustion. 
II.   The  intoxications  (toxic  insanities). 

I.    Acute  intoxications. 

a.  Febrile  delirium. 

b.  Intoxication  delirium. 


136  CLASSIFICATION. 

2.   Chronic  intoxications. 

a.  Alcoholism. 

b.  Morphinism. 

c.  Cocainism. 

III.    Metabolic  insanities  (autotoxic). 

a.  Myxedematous  insanity. 

b.  Cretinism. 

c.  The  dementia-producing  types. 

1.  Dementia  pnecox. 

2.  Catatonia. 

3.  Dementia  paranoides. 

4.  Dementia  paralytica. 

IV.   Insanities  from  organic  cerebral  disease. 
V.    Insanities  of  old  age. 

a.  Melancholia. 

b.  Senile  dementia. 

B.   Insanities  from  morbid  predisposition  [degenerative). 
I.   Constitutional  insanities. 

a.  Periodic  insanity. 

1.  Maniacal  form. 

2.  Circular  form. 

3.  Depressive  form. 

b.  Paranoia. 

1.  Combined  forms. 

2.  Hallucinatory  forms. 
II.   The  general  neuroses. 

a.  Epileptic  insanity. 

b.  Hysteric  insanity. 

c.  Shock  neuroses. 

III.  The  psychopathic  conditions. 

a.  Constitutional  "  Verstimmung  "  (insane  diathesis,  psychic  neu- 

rasthenia). 

b.  "  Zwangsirrsein  "    (phobias,  obsessions,  etc.). 

c.  Impulsive  insanity  (morbid  impulses,  etc.). 

d.  Contrary  sexual  feeling. 

IV.  The  defects  of  development. 

a.  Imbecility. 

b.  Idiocy. 

Note. — In  Kraepelin's  later  edition  (1899)  there  have  been  some  slight 
changes  in  this  classification. 

The  more  recent  French  classifications,  those  of 
Regis  (1892)  and  Dagonet  (1894),  are  quite  different 
from  the  above,  and  are  based  on  a  different  prin- 
ciple. That  of  Regis,  which  is,  in  its  way,  the  more 
philosophic  and  consistent  of  the  two,  divides  mental 


REGIS. 


137 


disorders  mainly  according  to  their  symptomatic  char- 
acters, giving  in  a  second  classification  the  associated 
forms,  arranged  according  to  the  bodily  disorders  they 
accompany,  and  to  which  they  are  commonly  attrib- 
uted in  the  etiologic  classifications,  like  those  of  Skae 
or  Clouston.  It  is  in  this  a  sort  of  pathologic  classi- 
fication imposed  upon  and  supplementary  to  a  symp- 
tomatic, and  has  the  advantage  of  completeness,  almost 
every  possible  type  being  included  under  some  one  of 
its  heads. 

CLASSIFICATION  OF  M.  REGIS  (1892). 
Primary  Conditions  of  Mental  Alienation. 


(i)  Mania 


Generalized  or 
Symptomatic  In- 
sanities. 


I.   Functional  Alienations  (Insanities,  Vesanias,  Psy- 
choses). 

Subacute  mania  (maniacal 
excitation). 

Acute  mania  (typical  mania). 

Hyperacute  mania  (acute 
delirium). 

Chronic  mania. 

Remittent  or  intermittent 
mania. 

Subacute  melancholia  (mel- 
ancholic depression). 

Acute  melancholia  (typical 
melancholia). 

Hyperacute  melancholia 
(melancholia  with  stupor) . 

Chronic  melancholia. 

Remittent  or  intermittent 
melancholia. 

Continuous  insanity  of 
double  form. 

Intermittent  insanity  of 
double  form. 

First  stage  (hypochondriacal 
insanity). 

Second  stage  (persecutory, 
religious,  political,  erotic, 
etc.,  insanity). 

Third  stage  (ambitious  in- 
sanity). 


(2)     Melancholia    or 
lypemania     .    .    . 


Partial  or  Essen- 
tial Insanities. 


(3)  Insanity  of  double 
form 


Systematized  progres- 
sive insanity      .    . 


138 


CLASSIFICATION. 


II.  Constitutional  Alienations  (Degeneracies,  Deviations, 
Mental  Infirmities). 

r  Defect  of  equilibrium,  orig- 
\       inality,  eccentricity. 
j  Fixed     ideas,      impulsions, 
\       aboulias. 

Delusional    (multiple    delu- 
sions of  degenerates). 
Reasoning  (reasoning  insan- 
ity, moral  insanity). 
Instinctive    (instinctive    in- 
sanity). 
Imbecility. 
Idiocy. 
Cretinism,  myxedema. 


Degeneracies  of 
Evolution  (Vices 
of  Organiza- 
tion). 


Disharmonies 
Neil  rasth  en  ias 


Phrenasthenias 


Monstrosities 


Degeneracies  of 
Involution  (Dis- 
organization). 


Dementias 


Simple  dementia. 


Secondary  Conditions  of  Mental  Alienation. 

(Associated  or  Symptomatic  Insanities.) 

I.  Physiologic  Conditions. 
(Sympathetic  Insanities.) 
Infancy.     Puberty (Hebephrenia;  pubes- 
cent insanity). 

Old  age (Senile  insanity). 

Menstruation      (Menstrual  insanity). 

Pregnancy {Puerperal  insanity). 

Menopause (Climacteric  insanity). 


II.  Local  Visceral  Disorders. 

(Sympathetic  Insanities.) 

I.   Genito-urinary  or-   r  Uterus  and  annexes 

gans \ 

v.  Kidneys  and  bladder  . 

!  Stomach  and  intestines 
Liver  and  bile  ducts  . 
Intestinal  worms      .    . 

3.  Circulatory   appa-    r  Diseases  of  the  heart  . 
ratus I-  Diseases  of  the  vessels 

4.  Respiratory  appa-  J 

)   Diseases  of  the  lungs  . 
ratus <-  & 


(Utero-ovai'ian  insan- 
ity). 

(Brightic  insanity). 

(Gastro-intestinal  insan- 
ity). 

(Hepatic  insanity). 

(Helminthic  insanity). 

(Cardiac  insanity). 


REGIS.  139 

III.  General  Diseases. 

(Insanity  of  Acute  Disorders.     Diathetic  Insanity.) 
Variola.      Erysipelas    .    .    . 

1.  Acute -{   Typhoid    fever.       Cholera. 

Grippe 

Intermittent  fever     ....  (Malarial  insanity). 

Rheumatism (Rheumatismal  insanity). 

Gout       (Podagrous  insanity). 

2.  Chronic    ...  /  Tuberculosis (Tubercular  insanity). 

Pellagra (Pellagrous  insanity). 

Cancer (Cancerous  insanity). 

Syphilis (Syphilitic  insanity). 

IV.  Diseases  of  the  Nervous  System. 

(Cerebrospinal  Insanities.     Neurotic  Insanities.) 

General  paralysis      ....  {Paralytic  insanity). 


I.   Cerebral  .    .    .    .    |  Local  brdn  disease 

Multiple  sclerosis 


„   .     ,  f  Locomotor  ataxia     ....  (Tabetic  insanity). 

2.   Spinal < 


Epilepsy {Epileptic  insanity). 

I   Hysteria.     Somnambulism.  {Hysteric  insanity) . 

,T  J  Chorea (Choreic  insanity). 

Neuroses      .    .    .      / 


Paralysis  agitans 
Exophthalmic  goiter 
Asthma 


V.  Intoxications. 

(Toxic  Insanities.) 

Alcoholism {Alcoholic  insanity). 

Saturnism (Saturnine  insanity). 

Morphinism (Morphinic  insanity). 

Hashischism (Hashisch  insanity). 

Etherism (Etheric  insanity). 

Chloralism (Chloralic  insanity). 

Cocainism (Cocainic  insanity). 

Oxy-carbonism (Oxy-carbonic  insanity). 

The  most  obvious  objection  to  this  classification  is 
its  elaborateness,  but  this  is  less  real  than  apparent. 
It  has  the  special  merit  of  prominently  bringing  forward 
a  class  of  mental  disorders  that,  while  not  so  frequently 
met  with  in  asylums,  and  therefore  not  commonly 
included  in  their  classifications,  is  liable  to  come  before 


140 


CLASSIFICATION. 


the  general  practitioner  at  any  time :  the  degenerative 
neurasthenics  and  sympathetic  insanities,  which  in 
their  milder  manifestations  are  far  from  uncommon  and 
need  recognition. 

One  of  the  most  recent  Italian  classifications  of 
mental  diseases  is  that  of  Agostini,  which  in  some 
respects  resembles  that  of  Kraepelin.  It  is  less  elab- 
orate and  lengthy  than  that  of  Regis,  and  differs  from 
that  of  the  German  alienist  in  the  different  estimate 
placed  upon  mania  and  melancholia,  which  are  not 
recognized  as  particularly  degenerative  or  periodic 
types.  In  this  last  view  Kraepelin  has  not  as  yet  a 
large  following,  though  in  a  modified  form  it  is  likely 
that  some  of  his  ideas  will  come  to  have  many  ad- 
herents. 


CLASSIFICATION    OF   AGOSTINI    (1 
GROUP  I. 


Mental  Disease"  in 
Normally  Devel- 
oped    Individuals. 


Functional     disorders 
of  general  metabolism. 

b.   Intoxications  or  acute 
infections. 


c.  Subacute  or  chronic 
intoxications  from 
auto-  or  hetero-toxic 
agents,  or  by  special 
poisons  or  drugs. 


d.  From  regressive  or 
degenerative  cerebral 
changes. 

From  diffuse  or  local 
cerebral  disease. 


Mania. 

Melancholic  insanities. 
Confusional  insanities. 
Stuporous  insanities. 

Acute  delirium. 

Paralytic  dementia. 
Pellagrous  insanity. 
Syphilitic  insanity. 
Myxedematous  insanity. 
Alcoholic  insanity. 
Saturnine  insanity. 
Carbonic  insanity. 
Morphinic  insanity. 
Cocainic  insanity. 

Senile  dementia. 
Secondary  dementia. 

Hemiplegic  dementia. 
Dementia     from    diffuse 

sclerosis. 
Dementia  from  cerebral 

compression,  etc. 


Arrests  or  Deviations 
of  the  Psychic  Fac- 
ulties in  the  De- 
generate. 


AGOSTINI. 
GROUP  II. 

Precocious  types. 
Late  types. 


141 


Idiocy. 
Imbecility. 
Endemic  cretinism. 
Original  paranoia. 
Rudimental  paranoia. 
Reasoning  insanity. 
Moral  insanity. 
Episodic  paranoia. 
Paranoia  tardive. 
Periodic  insanity. 
Catatonia. 


GROUP  III. 


Psychoses  Connected 
with  Neuropathic 
Constitution. 


Hysteric  insanity. 
Epileptic  insanity. 
Hypochondriac  insanity. 
Neurasthenic  insanity. 


Note. — The  following  is  the  latest  Italian  classification,  adopted  by  the 
Italian  Congress  of  Alienists  at  Ancona,  October,  1901  ("  Gaz.  degli  Ospe- 
dali,"  Oct.  13,  1901)  : 

1.  Congenital  Psychoses. — Arrests  and  deviations  of  psychic  development, 
phrenasthenias,  moral  insanity,  sexual  psychopathies. 

2.  Acitte  and  Simple  Psychoses. — Maniacal  and  melancholic  conditions, 
amentia,  hallucinatory  insanity. 

3.  Chronic  Psychoses,  Primary  and  Secondary . — Paranoia  ;  periodic  in- 
sanity ;  senile,  primary,  and  consecutive  dementia. 

4.  Paralytic  Psychoses. — Dementia  paralytica  (classic),  luetic,  alcoholic, 
encephalomalacic. 

5.  Psychoses  of  the  Netiroses. — Epileptic,  hysteric,  neurasthenic,  choreic, 
etc.,  insanities. 

6.  Toxic  Psychoses. — Pellagrous,  alcoholic,  morphinic,  cocainic,  etc.,  in- 
sanities. 

7.  Infectious  Psychoses. — Post-influenzal,  typhoidal,  syphilitic  insanities  ; 
acute  delirium. 

Dr.  F.  X.  Dercum  ("Jour.  Nerv.  and  Ment.  Dis.,"  Sept.,  1901)  proposes 
five  groups  of  mental  affections  only  : 
I.    Delirium,  confusion,  stupor. 
II.    Melancholia,  mania,  circular  insanity  (melancholia-mania). 

III.  Paranoia. 

IV.  Neurasthenic  insanities. 
V.    Dementia. 

These,  however,  require  subdivisions  according  to  developmental  periods, 
causes,  etc.,  and  the  apparent  simplicity  is  not  realized  to  the  fullest  extent. 
He  also  leaves  out  idiocy  and  imbecility  as  quantitative  defects  and  not  true 
insanities,  ignoring  their  close  relations  to  paranoia,  etc. 


142  CLASSIFICATION. 

The  following  is  a  comparatively  recent  (1897) 
English  classification — that  of  Andriezen.  It  has 
decided  merits,  but  its  novel  nomenclature  and  some 
other  features  are  likely  to  stand  in  the  way  of  its 
early  general  adoption. 

I.  Aphrenia  ;    arrest  of  psychic  development  with  absent  or  deficient  evolu- 
tion of  personality. 

a.  Somnolescent  vegetation  (paralytic  idiots,  etc.). 

b.  Medium  and  higher  grade  (microcephalic,  cretinoid,  myxedematous, 

idiots). 
II.   Oligophrenia.      Enfeeblements  and  diminutions  of  psychic  development. 

a.  Lower  grade  imbeciles. 

b.  Medium  grade  imbeciles. 

c.  Higher  grade  imbeciles. 

d.  Feeblemindedness. 

III.  Paraphrenia.      Anomalies  and  perversions. 

a.  P.  acuta  (eccentrics,  cranks,  mystics). 

b.  P.  gravis. 

1.  Observing  and  impulsive. 

2.  Persecutors.      Querulant. 

3.  Moral  insanity — sexual  pervert. 

4.  Congenital  criminals. 

5.  Paranoias. 

6.  Cyclic. 

7.  Epileptic,  hysteric,  neurotic. 

8.  Pubescent. 

IV.  Phrenopathia.      Morbid  condition  or  derangements  occurring  in  brains  of 

nearly  full    psychic  development  and  previous  health  with  corres- 
ponding morbid  alteration  of  personality. 

1.  Vesania  type  (melancholic  mania,  stupor,  confusion). 

2.  Toxic  type. 

3.  Febrile  micro-parasitic  types,  puerperal  acute  delirium,  etc. 

4.  Diathetic    group.      Derangement    of  metabolism    (myxedematous, 

acromegalic,  diabetic,  syphilitic  pseudo-paralysis). 

5.  Chronic  meningoencephalitis,  general  paralysis. 

6.  Involutional.     Chronic  cerebral  atrophy,  characteristic  seniles. 

7.  Traumatic. 

8.  Neoplastic  and  thrombotic  hemorrhages  and  neoplasms. 

The  fact  that  nearly  every  writer  on  insanity  has 
offered  his  own  classification,  differing  more  or  less 
from  that  of  any  other,  has  probably  had  its  influence 
in  discrediting  the  classifications  of  mental  diseases 
generally  in  the  public  mind.     The  fact  itself  indicates 


THE    AUTHORS    CLASSIFICATION.  143 

the  difficulties  that  any  attempt  of  this  sort  must  meet, 
and  the  wide  range  of  views  that  are  possible.  Insanity 
is  a  symptom  of  brain  disease,  and  we  know  as  yet  too 
little  of  all  the  multiform  functions  of  that  organ  to  be 
able  to  make  any  absolutely  correct  and  uniform  divi- 
sion of  its  disorders  that  is  likely  to  be  generally 
accepted.  The  classification  adopted  in  this  work  will 
be  a  simple  one.  The  general  principle  is  to  divide 
the  disorders  according  as  they  occur,  first,  in  a  nor- 
mally constituted  brain  and  mind ;  and,  second,  as  they 
occur  in  organizations  that  are  defective  from  the 
start.  It  does  not  follow  that  what  we  call  a  normally 
constituted  mind  may  not  be  in  some  respects  specially 
favorable  to  the  outbreak  of  mental  disease.  Absolute 
freedom  from  any  predisposition  is  too  rare  an  occur- 
rence to  be  reckoned  with.  The  difference,  however, 
between  the  degenerative  and  the  non-degenerative 
types  is  found  in  the  clearly  manifested  defective  con- 
stitution that  appears  to  be  closely  related  with  certain 
types  or  forms  of  insanity.  The  first  division,  there- 
fore, includes  the  alienation  that  may  occur  in  ordinarily 
well-constituted  individuals,  due  to  the  accidents  to 
which  every  one  is  liable,  overstrain,  toxic  agencies, 
traumatisms,  etc. 

In  this  division,  which  differs  from  that  of  Agostini 
and  its  arrangement,  we  include  also  the  insanities 
connected  with  the  general  neuroses  and  the  neurotic 
predisposition  which  is  not  directly  ascribable  to  a 
pronounced  general  degenerative  constitution.  These 
are  the  so-called  neuropathic  forms.  In  a  second  group 
we  have  the  evolutional  and  involutional  forms.  In 
the  third  group  we  have  the  insanities  of  the  degen- 
erates properly  so  called,  and  here  we  place  those  forms 
that  are  connected  with  gross  teratologic  defects. 
These  divisions  are  not  absolute,  and  there  is  a  possi- 
bility in  every  case  of  more  than  one  influencing  cause, 
but  they  are  adopted  for  their  convenience. 


144  CLASSIFICATION. 

In  the  first  group  we  do  not  include  the  common  form 
of  mania,  which,  following  Kraepelin,  is  placed  in  the 
degenerative  type.  As  regards  melancholia,  however, 
we  do  not  think  that  we  have  the  evidence  that  we  should 
have  to  refer  it  to  this  class.  Melancholia  occurs,  accord- 
ing to  our  experience,  in  much  the  same  form  in  both 
young  and  old,  though  predominantly  in  the  latter, 
and  Kraepelin's  division  of  it  into  a  depressive  form  of 
periodic  insanity,  and  a  true  melancholia  of  the  aged, 
does  not  seem  to  us  fully  justifiable. 

With  mania,  on  the  other  hand,  there  is  a  greater 
difficulty  in  deciding  its  proper  place  in  the  classifica- 
tion. Understanding  by  the  term  only  the  typical 
form,  which  almost  invariably  has  a  hereditary  history 
of  mental  disorder,  or  some  other  pronounced  neurotic 
or  neuropathic  heredity,  and  with  these  also  marked  de- 
generative stigmata,  it  would  not  appear  unnatural  to 
refer  it  to  the  degenerative  psychoses  that  do  not  occur 
in  the  normally  constituted  individual.  To  class  it  with 
the  periodic  insanities  because  of  the  likelihood  of  its 
recurrence,  as  does  Kraepelin,  seems  to  us  an  error;  its 
periodicity  is  too  irregular  to  be  called  such,  and  its 
absolute  certainty  of  recurrence  is  not  yet  satisfactorily 
established.  We  have  placed  it,  therefore,  in  the 
degenerative  forms,  as  it  were,  provisionally,  subject 
to  change  in  case  the  facts  appear  to  warrant  it  in  the 
future.  There  is  no  doubt,  as  Worcester  has  pointed 
out,  that  in  the  past  a  large  proportion  of  the  cases  of 
acute  confusional  insanity  have  been  classed  under  this 
head  in  the  statistics,  and  it  is  an  important  service  of 
Kraepelin's  work  that  it  emphasizes  the  distinction 
between  these  two  types.  Indeed,  in  many  of  the 
asylum  reports  of  this  country  and  Europe  no  such 
class  of  mental  disorders  as  confusional  insanity  has 
existed,  and  this  type  is  not  so  much  as  named  in  the 
international  classifications  of  1885  and  1889,  or  in 
that  of  the  International  Congress  of  Mental  Medicine 


ACQUIRED    INSANITIES.  145 

(1889),  a  fact  that  is  a  striking  commentary  on  the 
pathologic  conceptions  of  insanity  that  have  been  in 
vogue  up  to  recent  date. 

The  second  division  of  acquired  insanities  in  our 
classification  is  that  of  the  mental  disorders  from  direct 
drug  intoxications.  In  this  way  we  have  a  sort  of 
gradation,  and  the  real  difference  between  the  two 
types  is  not  so  great  as  to  justify,  in  our  opinion,  their 
complete  separation  from  each  other.  In  the  intoxica- 
tions, but  placed  by  itself,  we  include  paretic  dementia, 
as  probably  in  most  cases  a  parasyphilitic  disorder,  and 
in  any  case  as  the  result  of  an  active  toxin,  which,  if 
not  syphilitic  in  its  origin,  may  be  due  to  other  con- 
ditions, like  plumbism,  pellagra,  etc. 

The  fourth  division  gives  those  mental  disorders 
directly  connected  with  gross  organic  brain  disease, 
such  as  traumatic  insanity  from  brain  lesions,  and 
hemiplegic  insanity,  etc. 

The  fifth  group  of  acquired  mental  disorders  includes 
those  connected  with  neurotic  or  neuropathic  conditions. 
Under  this  head  we  have  hysteric  insanity,  epileptic  in- 
sanity, and  the  special  types  of  neurasthenic  derange- 
ment that  indicate  a  neuropathic  predisposition.  These 
disorders  are  very  often  reckoned  with  the  degenerative 
forms,  but  their  more  correct  place  appears  to  us  to  be 
among  the  acquired  forms  of  mental  disease.  Hysteria, 
which  of  itself  comes  nearest  to  a  degenerative  psychosis, 
is  a  latent  possibility  in  the  vast  majority  of  individuals, 
if  not  in  all  to  some  degree.  It  is  drawn  out  or  excited 
into  manifestations  by  various  causes,  chiefly  bad 
training,  psychic  or  physical  shock,  but  there  may  be 
also  other  exciting  causes.  Epilepsy  is  very  often,  if 
not  usually,  an  acquired  symptom,  and  the  same  is  true 
of  hypochondria. 

A  group  that  more  nearly  falls  between  the  acquired 
and  the  degenerative  mental  disorders  is  that  we  have 
called  the  insanities  of  critical  periods.     These  are  the 


146  CLASSIFICATION. 

forms  that  occur  under  stress  of  development  or  of 
regressive. changes ;  they  indicate  weakness,  but  are  not 
the  inevitable  or  the  easily  excited  types  of  the  gener- 
ally and  continuously  unstable  organization  that  we 
include  under  the  degenerative  psychoses. 

This  class  approaches  closely  to  the  degenerative 
insanities;  in  fact,  it  may  be  considered  as  a  sort  of 
connecting-link  or  intermediate  between  the  acquired 
mental  disorders  and  those  due  to  well-marked  degen- 
erative defects.  Under  these  latter,  which  comprise 
our  third  great  division,  the  insanities  of  the  degen- 
erates, we  have  included  circular  insanity,  paranoia, 
psychic  or  periodic  insanity,  and  the  various  types  that 
grade  down  finally  toward  imbecility  and  idiocy. 
Mania,  as  already  stated,  is  provisionally  put  in  this 
class. 

We  make  a  separate  group  for  the  borderland  and 
episodic  conditions  which  follow  the  degenerative 
insanities.  This  does  not  imply  that  these  are  all  more 
advanced  degenerative  states,  for  they  are  not;  they 
are  merely  considered  here  for  convenience,  as  they 
include  symptoms  ranging  from  comparatively  unim- 
portant and  temporary  neurasthenia  to  pronounced 
evidences  of  degeneracy.  They  clinically,  however, 
may  be  classed  with  the  other  forms,  and  they  have 
certain  features  in  common  that  make  their  considera- 
tion in  a  group  by  themselves  the  most  natural 
arrangement. 

As  regards  chronic  insanities,  no  attempt  has  been 
made  to  put  them  in  a  separate  division ;  they  may  all 
be  referred  to  one  type,  that  of  terminal  dementia,  in 
so  far  as  they  do  not  continue  in  a  chronic  form  the 
symptoms  of  their  acute  stage.  Thus,  paranoia  may 
never  pass  into  terminal  dementia.  The  same  is  true 
to  some  extent  of  other  forms,  such  as  mania  and  the 
different  types  of  cyclic  or  periodic  insanity. 

The  following  is  the  classification  that  has  been  out- 


THE    AUTHOR'S    CLASSIFICATION.  147 

lined  above,  and  which  will  be  followed  in  the  present 
volume : 

I.  Acquired  insanities.     Mental  disorders  of  the  normally  constituted. 

a.  Exhaustional  and  autotoxic  types,  including, 
Primary  confusional  insanity, 

Secondary  confusional  insanity, 
Melancholia. 

b.  Toxic  (drug)  insanities,  including, 
Alcoholic  insanity, 

Morphin  insanity, 
Cocain  insanity,  etc. 

c.  Paretic  dementia  (paresis). 

d.  Organic  insanities,  including, 
Hemiplegic  insanity, 
Traumatic  insanity. 

e.  Insanities  of  the  neuroses,  including, 
Epileptic  insanity, 

Hysteric  insanity,  etc. 
II.  Insanities  of  critical  periods — developmental  and  involutional. 

a.  Adolescent  insanity,  including, 

1.  Dementia  prsecox, 

2.  Catatonia. 

b.  Senile  insanity. 

c.  Climacteric,  etc.,  insanity. 

III.  Degenerative  psychoses,  including, 

a.  Mania, 

b.  Circular  insanity, 

c.  Paranoia,  including, 

1.  Systematized  delusional  type, 

2.  Original  paranoia. 

d.  Moral  insanity, 

e.  Imbecility, 

f.  Idiocy. 

IV.  Borderland  and  episodic  states,  including  obsessions,  phobias,  impulses, 

sexual  perversion,  etc. 
V.  Terminal  dementia. 

A  very  casual  examination  will  readily  show  the 
resemblances  between  this  classification  and  those  of 
Kraepelin  and  Agostini,  the  differences  being  mainly 
in  alteration  of  arrangement,  and  minor  details  that 
have  been  mentioned.  It  is  not  so  easy,  however,  to 
recognize  the  exact  equivalents  of  the  species  here  given 
and  those  of  Kraepelin  and  Regis,  representing,  as  it 


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150  CLASSIFICATION. 

were,  the  later  German  and  French  schools.  We 
therefore  offer  in  tabulated  form  what  seems  to  be  to 
us  the  nearest  equivalents  in  these  classifications,  and 
also  in  that  of  the  work  of  Spitzka,  which  has  been  in  its 
way  a  standard  in  this  country  for  many  years.  Here 
in  parallel  columns  are  given  the  names  of  the  types 
of  mental  disease  as  recognized  by  each  author  opposite 
the  species  corresponding  to  it  in  our  own  classifica- 
tion. The  advantage  of  this  appears  to  us  obvious,  as 
a  confusion  of  terms  that  exists  between  the  different 
nationalities  and  in  the  different  languages  is  a  real 
drawback  in  the  study  of  insanity.  For  many  years 
we  have  had  no  equivalents  in  our  terminology  for 
some  of  the  names  used  abroad,  and  the  absence  of  the 
term  to  some  extent  has  implied  also  the  lack  of  the 
proper  conception  of  the  species. 

It  is  well  to  bear  in  mind  that  any  classification, 
except,  perhaps,  the  most  simple  ones,  is  at  best  a 
compromise.  If  we  confined  ourselves  to  simply  divid- 
ing insanity  into  a  few  symptomatologic  groups,  we 
would  escape  many  difficulties,  but  the  security  would 
be  only  that  of  invincible  ignorance  that  pays  no  atten- 
tion to  any  but  the  most  simple  and  obvious  facts. 
All  the  acquisitions  of  late  years  would  have  to  be 
ignored,  and  the  satisfaction  that  some  have  expressed 
of  late  with  such,  as  compared  to  the  more  full  and 
elaborated  classifications,  is  hardly  creditable  to  them. 

With  the  multiplicity  of  actual  and  possible  causes 
of  insanity,  especially  of  the  forms  not  directly  asso- 
ciated with  direct  toxic  actions  or  gross  lesions,  it  is 
often  impossible  to  say  that  this  or  that  element  enters 
more  as  a  factor  into  the  causation  of  the  disorder,  and 
the  placing  of  any  individual  case  is  often  at  best  only 
provisional.  The  predisposition  that  has  been  already 
stated  to  exist  so  generally  has  always  to  be  reckoned 
with,  and  degeneracy  is,  as  applied  to  mankind,  only  a 
comparative  term;  the  individual  who  is  absolutely 


CLASSIFICATION.  151 

free  from  some  of  its  stigmata  and  some  of  its  active 
tendencies  in  all  probability  does  not  exist.  Therefore, 
our  distinction  of  acquired  and  degenerative  types  of 
mental  disorder  is  not  always  a  clearly  marked  one,  and 
patients  have  to  be  classified  according  to  the  most 
prominent  features  and  symptoms.  We  have,  how- 
ever, a  sufficiently  well-defined  set  of  syndromes  that 
in  most  cases  is  enough  for  our  purposes,  and  there  is 
no  reason  why  we  should  not  utilize  them. 


CHAPTER  X. 
THE  ACQUIRED  INSANITIES. 

By  the  acquired  insanities  we  understand  those  forms 
that  are  possible  in  normally  developed  individuals 
without  special  hereditary  or  congenital  defect  that 
would  more  or  less  inevitably  tend  to  the  production 
of  mental  disorder  under  favoring  conditions.  It  is  not 
intended  to  restrict  this  class  exclusively  to  normally 
constituted  individuals,  or  to  exclude  predisposition. 
They  are  as  liable  to  occur  in  predisposed  or  degenera- 
tive cases,  and  even  more  so ;  but  this  special  type  of 
insanity  is  such  that  it  might  occur  in  any  one 
with  sufficient  external  cause.  It  is  the  type,  not 
the  etiology  or  the  constitutional  conditions  and 
predilections  of  the  patient,  that  rules  the  classifica- 
tion. 

There  are  included  in  this  division  the  mental  dis- 
orders from  exhaustion  and  auto-intoxication,  which 
can  best  be  considered  together,  as  both  causes  very 
commonly  cooperate  in  the  etiology  of  the  insanity; 
the  strictly  toxic  insanities  due  to  poisons  introduced 
into  the  system  from  without,  the  organic  and  trau- 
matic insanities  caused  by  gross  organic  lesions  of  the 
brain,  and,  lastly,  the  insanities  of  the  neuroses,  which 
form  a  sort  of  transition  to  the  next  following  class: 
the  insanities  of  critical  periods,  or  those  occurring  at 
special  developmental  stages  when  the  special  stress 
upon  the  brain  and  nervous  system  is  in  excess.  Taking 
them  up,  therefore,  in  the  above  order,  we  have  first 
to  consider  the  exhaustional  and  auto-intoxication 
types. 

152 


CONFUSIONAL    INSANITY. 


PRIMARY    CONFUSIONAL    INSANITY.  1 53 

PRIMARY  CONFUSIONAL  INSANITY. 

Definition. — By  primary  confusional  insanity  we  un- 
derstand a  form  of  primary  mental  disorder  character- 
ized especially  by  marked  intellectual  impairment,  de- 
lirium, incoordination  of  ideas,  impaired  consciousness, 
and  generally  hallucinations  and  illusions,  and  some- 
times a  more  or  less  stuporous  condition,  occurring,  as  a 
rule,  after  severe  mental  or  physical  exhaustion,  or 
auto-intoxication  in  disordered  states  of  the  organism. 

The  simplest  and  most  familiar  type  of  the  disease  is 
the  temporary  delirium  of  fever,  which  is  hardly 
recognized  as  insanity,  and  which,  in  the  vast  majority 
of  cases,  passes  away  without  causing  permanent 
damage.  In  cases,  however,  that  properly  fall  in  the 
category  of  confusional  insanity,  the  direct  auto-intoxi- 
cation is  less  acute,  and  the  damage  to  the  mentally 
functioning  brain  elements  is  much  more  serious.  It 
stands  in  about  the  same  relation  to  febrile  delirium 
that  the  more  lasting  alcoholic  intoxication  or  alcoholic 
mental  derangement  does  to  acute  intoxication,  except 
that  it  is  not  so  commonly  preceded  by  repeated  tem- 
porary attacks.  As  alcoholic  insanity  may  occasion- 
ally occur  in  steady  drinkers  who  seldom  or  never 
exhibit  the  symptoms  of  acute  inebriety,  the  parallel 
is  not  so  incomplete. 

While  the  symptoms  of  this  type  of  insanity  have 
long  been  recognized  under  one  form  or  another,  for  its 
acceptance  as  an  independent  species  of  late  years  we 
are  largely  indebted  to  the  Germans,  with  whom  it 
has  passed  under  various  names,  as  amentia,  acute 
hallucinatory  "  Verwirrheit,"  etc.  Spitzka  (1877)  in 
this  country  was  one  of  the  very  first,  if  not  actually 
the  first,  to  recognize  and  describe  its  typical  form  as 
an  independent  entity.  Chaslin  (1895),  "  La  Confusion 
Mentale  Primitive,"  has  given  an  excellent  monograph 
on  this  subject,  in  which  the  historic  data  are  very 


154  THE    ACQUIRED    INSANITIES. 

fairly  summed  up,  and  it  does  not  appear  from  it  that 
any  author  really  antedated  Spitzka  in  the  first  edition 
of  his  excellent  manual  on  insanity,  published  in  1877. 
At  the  present  time  it  has  not  yet  commonly  won  a 
place  in  asylum  statistics,  but  its  general  recognition 
is  probable  in  the  near  future,  the  more  so  since  it  has 
the  sanction  of  some  of  the  more  recent  foreign  treat- 
ises, such  as  those  of  Kraepelin  and  Agostini. 

As  here  understood,  the  species  is  more  comprehen- 
sive than  is  that  of  Kraepelin,  whose  "collapse  de- 
lirium," acute  "  Verwirrheit,"  and  dementia  acuta  are 
here  all  included  under  the  same  general  head  of 
primary  confusional  insanity.  It  has  seemed  better 
to  do  this,  to  consider  them  as  varieties  of  one  species, 
rather  than  as  distinct  clinical  forms  always  recogniz- 
able, and  not  so  intimately  related  as  we  must  admit 
them  to  be.  They  have,  in  the  main,  and  as  acute 
conditions,  the  same  etiology,  and,  as  Kraepelin 
admits,  the  same  marked  disorders  of  understanding, 
of  connection  of  ideas,  and  of  the  mental  reaction  to 
external  impressions  and  representations.  Their  treat- 
ment is  practically  the  same,  only  varying  with  minor 
and  special  individual  conditions.  They  graduate  also 
into  each  other,  so  that  every  variation  can  be  found 
between  the  most  excited  collapse  delirium  at  the  one 
extreme,  to  almost  absolute  stuporous  insanity  at  the 
other.  To  quote  Kraepelin  again,  his  acute  "Verwirr- 
heit "  can,  in  a  certain  sense,  be  called  a  prolonged 
collapse  delirium,  and  his  acute  dementia  may  begin 
with  the  characteristic  symptoms  of  either  of  these 
types. 

With  this  more  comprehensive  concept  of  confusional 
insanity  it  is  therefore  necessary  to  recognize  as  phases 
or  varieties  of  the  disorder  the  more  striking  modifica- 
tions of  the  type.  This,  however,  need  not  be  done 
formally  under  different  heads,  at  least  as  regards  the 
first   two,    the    "collapse    delirium"    and    the    acute 


PRIMARY    CONFUSIONAL    INSANITY.  155 

"  Verwirrheit "  of  Kraepelin.  The  deeper  involvement 
of  the  intellectual  and  sensory  centers,  as  shown  in  the 
condition  called  by  him  "acute  dementia,"  and  which 
in  its  extreme  phase  includes  what  has  been  known  as 
stuporous  insanity,  is  clinically  more  distinct,  and 
possibly  deserves  a  separate  heading,  as  a  more  marked 
variety,  such  as  had  been  given  it  by  some  recent 
authorities  who  have  treated  of  the  subject  (Agostini, 
Kraepelin,  et  al.).  Collapse  delirium  and  acute  hal- 
lucinatory delirium  pass  into  each  other  imperceptibly 
— there  are  cases  which  it  is  hard  to  say  to  which 
category  they  belong.  It  is  sometimes  the  case  that 
the  more  acute  cases  with  apparent  shorter  duration 
may  relapse  after,  as  it  were,  passing  into  the  con- 
valescent stage,  and  become  typical  confusional  in- 
sanity, lasting  for  weeks  and  months.  A  little  error 
in  the  treatment,  or  some  unavoidable  accident,  may 
change  the  apparently  more  acute  delirious  attacks  to 
the  more  lasting  phases.  From  these  considerations  we 
do  not  here  recognize  the  two  types  as  more  than  the 
variations  of  a  single  species  of  mental  disorder. 

Etiology  and  Frequency. — Aside  from  predisposition 
or  original  defect,  which  may,  of  course,  coexist  without 
affecting  the  status  of  this  disorder  as  an  acquired 
insanity,  and  other  factors  indirectly  favoring  its  occur- 
rence, the  chief  causes  of  confusional  insanity  are  those 
that  directly  affect  the  nutrition  of  the  brain,  or  ex- 
haustion from  excessive  mental  strain  in  some  form  or 
other.  Thus,  the  puerperal  state  and  lactation  may 
be  reckoned  as  amongst  the  most  frequent ;  then  come 
exhausting  acute  disease,  mental  overwork  or  excite- 
ment ;  and,  lastly,  in  all  probability  excessive  emotional 
excitement.  Just  the  proportional  part  that  the  ex- 
haustion of  the  brain-cells  and  auto-intoxications  occur- 
ring in  connection  with  the  above-named  causes  play, 
is  hard  to  decide,  and  the  question  will  be  more  thor- 
oughly discussed  under  the  head  of  pathology.     There 


156  THE    ACQUIRED    INSANITIES. 

is  little  question,  however,  but  that  both  these  elements 
have  a  share  in  its  causation,  and  that  the  morbid  con- 
ditions due  to  fatigue  in  themselves  are  attended  with 
the  production  of  toxins  that  may  react  on  their 
originating  cells  or  organs,  and  their  functions. 

Kiernan  *  reports  cases  due  to  fright,  rheumatic  in- 
fection, lead-poisoning,  etc.,  and  considers  nervous 
asthenia  as  the  underlying  condition.  He  quotes 
Kraepelin  and  Moeli  as  holding  a  similar  view  and 
making  the  nerve  exhaustion  rather  than  the  toxemia 
the  leading  factor.  This  is  probably  correct  in  the 
main,  but  the  toxin  element  cannot  be  altogether  un- 
considered in  many  cases,  at  least,  as  a  factor  in  the 
nerve  exhaustion  itself;  the  latter  is  sometimes  the 
leading  manifestation  of  the  toxic  action.  The  rapidity 
with  which  the  etiologic  factors  develop  is  held  by 
some  (Binswanger)  as  having  an  important  influence 
on  the  form  of  the  disorder.  The  more  long  continued 
the  prior  exhausting  influence,  the  more  prominent  are 
the  inhibitory  symptoms  (stupor,  etc.),  while  the  irri- 
tative symptoms  follow  more  usually  in  the  cases  of 
quick  development  and  less  prolonged  antecedents. 
This,  however,  is  only  true  to  a  certain  extent;  the 
intensity  of  the  impression  on  the  nervous  system  and 
its  special  idiosyncrasies  in  any  individual  case  have 
more  to  do  in  many  cases  than  the  length  of  time  they 
have  been  acting. 

As  rule,  there  must  be  a  weakened  organism  or  a 
special  predisposition  to  form  the  favoring  soil  upon 
which  these  causes  may  produce  their  morbid  product. 
This  is  readily  supplied  by  the  physical  conditions  of 
an  exhausting  parturition,  or  an  acute  attack  of  fever, 
for  example,  in  those  who  have  not  a  congenital  weak- 
ness to  favor  the  outbreak.  Long-continued  night 
watching  without  compensating  sleep  by  day,  espe- 
cially if  accompanied  with  anxiety,  may  be  a  cause; 

*"Med.  Standard,"  July,  1895. 


PRIMARY    CONFUSIONAL    INSANITY.  157 

excessive  political  or  religious  excitement  also  is  occa- 
sionally credited  with  producing  it,  and  it  is,  as  Regis 
has  pointed  out,  the  most  marked  type  of  the  insanity 
that  sometimes  follows  surgical  operations — the  so- 
called  post-operative  insanity.  Typhoid  fever,  influ- 
enza, and  other  exhausting  disorders  in  which  there 
enters  also  an  element  of  auto-intoxication  are  also 
frequent  causes,  and  we  may  sum  up  the  etiology  by 
saying  that  it  embraces  whatever  may  lead  to  rapid 
exhaustion  of  the  cerebral  nervous  centers. 

Primary  confusional  insanity  in  one  or  another  of  its 
types  or  phases  is  not  an  infrequent  form  of  mental 
disorder ;  the  more  acute  and  typical  form,  the  collapse 
delirium  of  Kraepelin,  is  possibly  the  most  frequent, 
and  is,  as  has  been  stated,  not  uncommonly  classed  as 
mania  in  the  average  asylum  classifications.  The  more 
long-continued  form,  the  "amentia,"  is  probably  less 
frequent,  and  the  more  or  less  stuporous  type  is  by  no 
means  rare.  It  is  difficult  to  say  what  proportion  of 
all  the  cases  of  insanity  all  these  forms  together  make, 
on  account  of  the  very  common  failure  to  recognize 
them  as  distinct  clinical  species ;  there  has  been,  indeed, 
a  confusion  of  ideas  in  regard  to  them,  and  that  state 
exists  even  in  comparatively  recent  text-books  on  in- 
sanity, and  has  greatly  obscured  the  subject,  and  led 
to  almost  a  complete  absence  of  statistics.  It  does 
not  appear  improbable,  however,  that  of  strictly  recent 
cases  it  forms  a  very  considerable  percentage;  not  less, 
at  the  least  calculation,  than  10  to  15%.  Counting 
only  the  acquired  insanities  by  themselves,  and  exclud- 
ing the  degenerative  and  neurotic  types,  the  proportion 
would,  of  course,  be  still  larger. 

Symptoms. — With  the  more  comprehensive  concep- 
tion of  confusional  insanity  given  above,  there  must  of 
necessity  be  a  wider  range  of  symptoms  than  some  have 
attributed  to  it,  including,  as  it  does,  not  only  the 
delirious    types,    but    also    the    more    depressed    and 


158  THE    ACQUIRED    INSANITIES. 

stuporous  ones.  In  describing  the  clinical  phenomena 
of  the  disorder  here,  all  these  will  be  noticed  in  their 
natural  connection,  without  attempt  at  formally 
separating  the  types  or  varieties. 

In  a  large  proportion  of  cases  the  onset  is  sudden; 
the  patient,  while  he  may  be  aware  of  having  over- 
worked his  brain,  or  otherwise  undergone  a  mental  or 
physical  strain,  is  apparently  not  aware  of  any  special 
change  in  his  health,  and  the  onset  of  the  attack  is 
unanticipated.  One  such,  who  preserved  some  sort  of 
recollection  of  what  he  passed  through  when  he  was 
taken  suddenly  when  traveling  on  a  railroad  train, 
endeavored  to  vividly  describe  the  hallucinations  and 
ideas  that  then  possessed  him.  As  far  as  he  could 
remember,  they  were  those  of  impending  danger,  but  at 
best  it  was  a  sort  of  confused  dream,  which  soon  passed 
into  a  condition  of  which  he  had  no  recollection  what- 
ever. Such  patients  are  rare,  and  we  generally  have  to 
endeavor  to  appreciate  their  mental  condition  by  their 
objective  symptoms  and  speech.  In  the  more  acute  form 
(collapse  delirium)  they  show  from  the  first,  as  a  rule,  a 
loss  of  appreciation  of  their  surroundings ;  their  intellec- 
tion is  embarrassed,  the  ideas,  while  flowing  incoherently 
and  disconnectedly  from  the  first,  indicate  when  closely 
studied  an  actual  retardation  rather  than  an  accelera- 
tion of  mental  action.  The  patient  repeats  meaning- 
less phrases,  seemingly  disconnected  portions  of  sen- 
tences, as  if  his  ideas  were  broken  off  in  the  middle;  or 
he  may  talk  a  little  more  connectedly,  as  if  under  a 
host  of  fleeting  and  disconnected  deliriums  or  hallucina- 
tions. He  is  in  heaven  or  hell,  is  general  of  armies,  or 
is  to  be  crucified;  all  these  rapidly  changing  from 
minute  to  minute.  The  hallucinations  and  illusions 
are  mostly  visual,  but  may  involve  any  of  the  senses. 
They  relate  to  the  surroundings,  or  the  identity  of  in- 
dividuals about  him;  he  is  in  a  palace,  is  surrounded 
by  devils,  saints,  or  angels.     Perfumes  or  foul  odors 


PRIMARY    CONFUSIONAL    INSANITY.  1 59 

are  thrown  upon  him,  etc.  Not  infrequently  they 
may  have  an  erotic  tinge;  the  patient  believes  he  is 
under  the  influence  of  love  potions,  etc.,  and  the  acts 
may  be  in  accordance.  There  is  often  a  tendency  in 
the  speech  to  alliteration,  and  there  can  sometimes  be 
apparently  traced  a  connection  of  sound  without  sense 
between  the  words  or  phrases.  The  speech  often 
seems  to  be  only  a  sort  of  an  automatic  verbigeration, 
with  only  a  faint  indication  of  any  intellectual  process. 

The  emotional  condition  in  these  more  acute  cases  is 
generally  rather  exalted  than  depressed,  but  there  may 
be  with  the  rapidly  changing  kaleidoscopic  impressions 
spells  of  terror,  leading  to  acts  of  sudden  violence. 
One  patient  who  was  of  this  general  type,  for  a  time  in 
the  experience  of  the  writer,  was  one  of  the  most  diffi- 
cult patients  in  a  large  hospital  to  manage,  because  of 
this  tendency,  and  the  intense  motor  excitement.  He 
could  not  be  well  managed  by  two  or  more  attendants 
on  account  of  his  physique  and  the  quickness  of  his 
movements,  and  isolation  under  close  observation  was 
for  a  time  the  only  seemingly  practicable  resource. 
Such  cases  are  rare  in  acute  confused  insanity,  but  they 
sometimes  occur,  and  extreme  motor  excitement  is  not 
altogether  uncommon  in  very  well-marked  cases  of  this 
acute  type. 

The  majority  of  the  cases  of  acute  confusional  in- 
sanity, aside  from  those  following  childbed  and  acute 
diseases,  probably  begin  in  this  way,  with  few  pre- 
monitions, except  that  the  patient  may  feel  that  he  is 
overworked,  and  is  not  in  his  best  condition,  is  suffering 
from  constipation,  etc.  In  other  cases,  however,  there 
are  premonitory  symptoms,  restlessness,  insomnia,  a 
certain  degree  of  mental  depression  preceding  the  out- 
break by  a  few  days  or  a  week  or  two,  in  some  cases 
even  over  a  month.  With  this  less  rapid  onset  of  the 
attack  there  is  a  more  gradual  development  of  the 
symptoms,  and  the  more  or  less  intense,  often  slightly 


l6o  THE    ACQUIRED    INSANITIES. 

erotic  and  hilarious  excitement,  is  no  longer  the  rule. 
The  patient  is  as  much,  or  more,  likely  to  be  depressed 
rather  than  excited.  In  some  cases  the  mental  con- 
fusion, though  existent  and  well  marked,  may  come  on 
so  insidiously  that  the  casual  observer  may  not  recog- 
nize the  mental  condition,  especially  if  it  is  attended 
by  taciturnity,  as  is  sometimes  the  case.  It  may  vary 
also  in  degree ;  the  patient  may  still  be  able  to  partially 
or  occasionally  orient  himself,  as  in  an  instance  under 
observation,  where  a  man  wandered  away  from  home, 
and  was  yet  able  once  or  twice  to  direct  incoherent 
communications  to  his  friends,  though  with  no  recollec- 
tion of  having  done  so  later.  This  case  will  be  more 
fully  noticed  when  speaking  of  the  later  stages  of  the 
disorder. 

When  the  disorder  appears  after  childbirth,  acute 
febrile  infections,  or  exhaustive  loss  of  blood,  the  course 
is  commonly  the  same ;  the  onset  of  the  mental  disorder 
may  be  sudden  or  gradual,  but  the  early  course  of  the 
affection  is  modified  by  the  physical  condition  of  the 
patient;  there  is  less  likely  to  be  excessively  stormy 
agitation,  for  the  simple  reason  of  the  weakness  follow- 
ing the  original  cause.  A  very  large  proportion  of  the 
cases  of  so-called  puerperal  insanity  are  of  this  type — 
an  acute  hallucinatory  delirium,  with  mental  con- 
fusional  symptoms  marked.  Occasionally  the  begin- 
ning is  so  gradual  that  the  patient  herself  is  aware  of 
the  condition,  and  may  even  seek  advice  and  treatment 
after  the  incoherence  and  inability  to  express  herself 
or  describe  her  symptoms  is  well  established.  There 
may  be,  lastly,  in  some  cases  a  stuporous  tendency  from 
the  beginning;  in  short,  there  is  every  variety  in  the 
mental  symptoms  of  the  incipient  disorder,  ranging 
from  acutely  maniacal-appearing  agitation  to  more  or 
less  complete  apparent  apathy  or  dementia. 

As  the  mental  disorder  progresses,  the  symptoms 
usually  become  more  marked  after  the  immediate  onset, 


PRIMARY    CONFUSIONAL    INSANITY.  l6l 

the  mental  confusion  becomes  more  pronounced,  the 
hallucinations,  which  are  the  rule,  more  evident,  and 
whatever  consciousness  or  memory  of  his  or  her  con- 
dition the  patient  may  have  possessed  up  to  this  time 
is  commonly  lost.  The  motor  impulsion,  which  in  the 
severer  cases  stimulates  actual  maniacal  furor,  soon 
reaches  its  height  when  it  occurs.  In  the  more  slowly 
progressing  form  the  emotional  condition,  while  most 
frequently  more  or  less  of  the  depressive  type,  may 
also  take  on  an  excited  form,  and  a  mildly  hilarious 
grand  delirium,  or  delusions  of  exaltation,  may  appear, 
even  in  the  cases  where  the  physical  depression  is  most 
strikingly  marked.  Patients  in  this  condition,  how- 
ever, are  rather  exceptional ;  the  general  rule  is  a  con- 
fused depression.  They  appear  often  as  if  they  were 
wondering  why  they  were  depressed,  and  are  not  so 
commonly  actively  and  obstinately  inclined  to  self- 
depreciation  or  self -injury  as  melancholiacs,  with  whom 
they  have  often  been  classed ;  or  if  otherwise,  it  is  but 
momentary,  and  under  some  special  stress  of  agitation. 
They  may  be  mildly  resistant  in  an  aimless,  semi-pas- 
sive way,  but  rarely  more  than  this. 

With  the  mental  changes,  there  are  generally  parallel 
physical  symptoms.  The  condition  after  exhausting 
fevers  or  other  diseases,  childbirth  or  lactation,  or  often 
extensive  hemorrhages,  is,  of  course,  one  of  exhaustion, 
anemia,  and  malnutrition,  and  in  the  post-febrile  cases 
we  have  also  the  special  toxins  to  reckon  with  as  prob- 
able disturbers  of  the  bodily  health.  In  those  credited 
to  overwork,  and  especially  to  sudden  shocks  or  strains, 
the  general  physical  condition  may  be  better,  and  the 
muscular  power  particularly  be  retained  to  a  very 
large  extent,  so  that  such  patients,  under  the  influence 
of  their  fleeting  delusions,  may  be  at  times  quite  diffi- 
cult to  manage,  and  in  the  very  acute  and  rapid  cases 
of  so-called  collapse  delirium  there  may  be  no  very 
serious  physical  depreciation  decidedly  visible  till  the 


162  THE    ACQUIRED    INSANITIES. 

relaxation  of  the  strain  toward  the  beginning  of  con- 
valescence. But  even  in  these  cases  there  may  be 
manifest  bodily  symptoms,  and  there  is  almost  in- 
variably a  disordered  digestive  tract,  as  shown  by  foul 
breath,  a  coated  tongue,  and  generally  an  obstinate 
constipation.  In  some  rare  cases  the  depraved  phys- 
ical condition  ma}^  go  so  far,  even  without  attendant 
stupor,  as  to  produce  local  disorders  of  the  circulation, 
edema,  local  asphyxia,  or  even  bed-sores  very  early 
in  the  disease.  The  appetite  is  commonly  poor  or  lost, 
and  artificial  feeding  may  be  required.  Constipation 
is  the  rule,  but  may  alternate  with  diarrhea. 

In  a  certain  proportion  of  cases  which  usually  com- 
mence as  described,  the  mental  condition  passes  in  a 
few  days  or  weeks  to  a  more  or  less  profoundly  stupor- 
ous condition.  This  may  vary  from  a  state  in  which 
the  patient  sits  or  stands  in  a  dull  apathetic  way,  but 
can  still  be  roused  to  answer  questions  in  a  confused 
manner,  or  may  even  have  a  set  of  phrases  which  he 
repeats,  to  complete  apparent  abolition  of  mental 
activity.  The  patient  may  occasionally,  but  rarely, 
have  sudden  spells  of  agitation,  or  there  may  be 
remissions  in  which  the  intellectual  activities  seem  to 
be  again  aroused,  only  to  fall  back  into  his  old  condi- 
tion. In  other  cases  there  is,  with  this  semi-stuporous 
condition  above  mentioned,  a  sort  of  agitation,  a 
mumbling  of  incoherent  phrases,  the  patient  may  per- 
form acts  without  motive,  and  be  to  a  certain  extent 
destructive  of  clothing,  etc.,  and  may  masturbate 
constantly.  This  condition  in  any  of  its  forms  rarely 
appears  at  once,  but  is  generally  preceded  by  a  period 
of  confusional  delirium  similar  to  that  described  already 
as  typical  of  this  general  type  of  mental  disorder;  in 
fact,  it  is,  as  a  rule,  the  outcome  and  aggravation  of 
those  forms  called  collapse  delirium  or  acute  confu- 
sional insanity,  and  especially  of  the  former,  when  it 
does  not  tend  to  early  recovery. 


PRIMARY    CONFUSIONAL    INSANITY.  163 

It  is  in  this  form  particularly  that  the  bodily  symp- 
toms are  most  marked.  The  patient  lies,  sits,  or 
stands  impassive,  and  generally  expressionless ;  only  in 
the  partial  forms  is  there  sometimes  a  sort  of  distressed, 
puzzled  look,  as  if  apprehending  to  an  extent  his  con- 
dition. In  the  fully  developed  cases  the  pupils  are 
dilated  and  the  eyes  seem  dull;  the  face  is  pale;  the 
mouth  is  apt  to  be  partially  open,  and  it  may  be  drool- 
ing saliva ;  the  tongue  is  thickly  coated,  the  breath  foul ; 
the  pulse  is  feeble,  the  temperature  often  subnormal, 
but  liable  in  some  cases  to  febrile  exacerbations,  even 
reaching  400  C.  (1040  F.)  (Sauze,  quoted  by  Chaslin) ; 
the  hands  and  feet  are  often  blue,  swollen,  the  sensi- 
bility and  the  reflexes  diminished;  the  appetite  is  lost 
and  the  general  condition  of  malnutrition  marked. 
Occasionally  there  is  a  slight  approach  to  cataleptic 
muscular  rigidity;  the  patient  neglects  calls  of  nature, 
and  passes  the  urine  and  feces  without  any  attempt  at 
control  or  regard  for  time  or  place.  If  questioned,  it 
is  only  with  difficulty  that  any  answer  can  be  obtained, 
and  then  it  is  given,  if  at  all,  with  extreme  embarrass- 
ment and  slowness. 

There  is  every  variety  between  this  complete  stupor- 
ous type  of  the  disorder  and  the  less  profound  acute 
confusional  insanity,  as  there  is  also  between  the  latter 
and  the  more  agitated  and  maniacal  type  of  collapse 
delirium.  These  physical  symptoms  may,  therefore, 
be  seen  in  part  existing  in  the  other  phases,  but,  as 
given  above,  they  are  best  seen  combined  and  fully 
developed  in  the  typical  stuporous  insanity.  The 
maniacal  form  is  usually  of  shorter  duration,  and  affects 
the  physical  condition  of  the  patient  least;  certainly 
this  is  the  case  while  it  continues ;  thus,  the  more  slowly 
developing  confusional  type,  following,  as  it  does  very 
often,  depressing  fevers  and  other  diseases,  has  the 
somatic  phenomena  more  pronounced,  while  in  the 
fully  developed  acute  dementia  or  stuporous  insanity 


164  THE    ACQUIRED    INSANITIES. 

they  are  most  marked  of  all.  It  is  only  in  very  rare 
and  exceptional  cases — and  this  it  is  possible,  in  those 
where  a  hereditary  and  degenerative  taint  is  strong, 
thus  to  a  certain  extent  making  their  reference  to  the 
category  of  acquired  insanities  a  somewhat  dubious 
one — that  we  find  complete  stupor  occurring  without 
these  very  notable  indications  of  general  somatic  dis- 
turbance existing  to  a  very  marked  extent. 

The  so-called  acute  delirium  is  often  only  the  hyper- 
acute phase  of  confusional  insanity  from  exhaustion 
or  toxemia.  In  this  case  the  process  is  a  more  active 
one,  the  cortical  changes  become  more  pronounced, 
and,  correspondingly,  we  have  the  more  marked 
somatic  symptoms  indicating  actual  meningeal  and 
cortical  inflammation.  The  patient  is  acutely  delirious ; 
insomnia  is  absolute ;  the  temperature  often  runs  up  to 
1030,  1040,  or  higher;  there  is  extreme  motor  restless- 
ness, together  with  rapid  physical  exhaustion.  Appe- 
tite is  lost,  the  teeth  become  covered  with  sordes,  and 
the  final  stage  is  one  of  low  typhoidal  delirium  with 
generally  a  fatal  ending.  While  the  clinical  syndrome 
may  occur  as  a  complication  of  other  forms  of  mental 
disorder,  notably  in  paresis,  yet  in  the  so-called  primary 
cases  it  is  often  only,  as  said  above,  an  aggravated  form 
of  the  same  toxic  or  exhaustional  condition  that  more 
commonly  reveals  itself  as  the  ordinary  confusional 
insanity.  The  macroscopic  changes  observed  in  the 
brain  in  fatal  cases  of  this  type  are  those  of  intense 
meningeal  and  cortical  congestion,  and  microscopically 
the  nerve-cells  show  swelling,  pigmentation  (especially 
of  the  giant  cells  of  Betz),  and  sometimes  breaking 
down  in  all  layers  of  the  cortex  of  nearly  all  parts. 
Alzheimer  has  distinguished  five  different  types  of  acute 
delirium  according  to  the  nature  and  extent  of  these 
changes,  some  of  them  especially  characteristic  of  those 
cases  due  to  exhaustion  or  intoxication. 

Course  and  Termination. — The  course  of  the  disease 


PRIMARY    CONFUSIONAL    INSANITY.  165 

varies  with  its  form.  In  the  acute  collapse  delirium 
type  it  may  last  only  a  few  days;  rest,  good  feeding, 
and  attention  to  the  state  of  the  bowels  and  sleep 
bringing  on  a  rapid  cure.  Sometimes,  however,  as 
already  indicated,  a  marked  apparent  improvement 
may  be  followed  by  a  relapse,  and  the  patient  either 
have  a  repetition  of  the  former  symptoms,  or  pass  into 
one  of  the  longer  continued  forms.  In  favorable  cases 
of  the  more  acute  form  of  confusional  insanity  there  is 
sometimes  a  sudden  and  complete  recovery,  but  more 
often,  after  a  few  days  or  weeks,  the  sufferer  begins 
to  change  for  the  better,  the  agitation  disappears,  the 
mental  confusion  clears  up  to  a  large  extent,  the  sleep 
returns,  and  the  appetite  becomes  even  excessive. 
There  may  be  for  a  considerable  time  some  remnants 
of  the  confusional  condition,  some  incoherence  of  ideas, 
and  some  delusional  notions;  but  these  generally  pass 
away,  at  least  to  a  very  great  extent,  and  the  patient  is 
practically  well.  Recovery  with  defect  may  occur,  but 
considerable  permanent  mental  impairment  is  the  excep- 
tion in  this  more  acute  form,  when  it  passes  quickly  to 
recovery.  In  very  acute  cases  the  condition  sometimes 
becomes  so  aggravated  as  to  cause  fatal  exhaustion 
before  any  letting-up  of  the  symptoms  may  occur,  or 
the  syndrome  may  even  be  that  of  acute  delirium  with 
high  temperature,  and  all  the  signs  of  profound  inflam- 
matory meningeal  and  cortical  involvement.  Many 
cases  of  so-called  primary  acute  delirium  or  typho- 
mania  are,  as  already  said,  doubtless  instances  of  this 
termination  of  acute  confusional  insanity. 

The  less  acute  type,  the  "amentia"  of  the  German 
authors,  is  more  chronic  in  its  course,  and  lasts,  as  a 
rule,  for  weeks  and  months  instead  of  days  or  weeks. 
Its  course  is  liable  to  be  interrupted  by  partial  remis- 
sions that  may  cause  hopes  of  a  quick  recovery,  only  to 
be  disappointed  by  a  speedy  relapse ;  but  in  other  cases, 
and  more  often,  the  disorder  is  continuous  for  weeks, 


166  THE    ACQUIRED    INSANITIES. 

and  the  recovery  is  gradual;  exacerbations  of  excite- 
ment and  of  the  mental  confusion  are  even  more  likely 
to  be  observed  than  are  remissions,  and  these  are  apt 
to  follow  some  systemic  disturbance,  like  the  occur- 
rence of  the  menses,  etc.  Death,  when  it  occurs,  may 
be  due  to  marasmus,  but  is  more  likely  to  be  the  result 
of  some  intercurrent  disorder,  like  pneumonia,  which 
finds  a  less  resistant  organism  from  the  general  state 
of  the  patient.  The  passage  from  this  into  the  third 
state,  that  of  acute  dementia,  or  stuporous  insanity, 
is  not  uncommon.  Recovery,  generally  with  some 
defect,  in  these  cases  may  occur  even  after  many  years. 
One  case  observed  by  us  made  a  very  fair  recovery 
after  five  years,  during  the  last  two  or  three  of  which 
she  had  been  absolutely  demented  to  all  appearance — 
untidy,  drooling  saliva  to  the  amount  of  pints  daily, 
and  unable  even  to  attend  to  her  simplest  wants.  Few 
cases,  however,  recover  even  partially  after  so  long  a 
period  as  this;  one  or  two  years  is  generally  the  limit. 

The  patient  whose  insanity  continues  longer  than 
this  is  more  liable  to  pass  into  a  state  of  chronic 
secondary  or  terminal  dementia,  in  which  the  con- 
fusional  type  can  often  still  be  recognized.  The 
physical  condition  improves  and  the  mental  symptoms 
become  chronic. 

In  the  lighter  forms  of  stuporous  or  semi-stuporous 
insanity,  especially  those  more  depressed  forms  follow- 
ing childbed  or  exhausting  lactation,  the  mental  symp- 
toms may  disappear  rapidly,  with  improvement  in  the 
bodily  health,  and  the  same  may  also  be  the  case,  but 
more  rarely,  in  some  instances  occurring  after  acute 
infectious  diseases.  Usually  with  this  type  the  im- 
provement, when  it  occurs,  is  slow;  the  patient  gradu- 
ally comes  to  a  realization  of  his  surroundings,  begins 
to  act  and  care  for  himself,  and  occasionally,  it  may  be 
after  one  or  more  partial  relapses,  makes  an  approx- 
imate recovery,  but  usually  with  more  or  less  permanent 


PRIMARY    CONFUSIONAL    INSANITY.  167 

mental  defect.  On  the  other  hand,  the  more  common 
outcome  is  the  chronic  terminal  dementia ;  the  improve- 
ment is  checked  at  an  earlier  stage,  and  the  mental 
impairment  remains  so  pronounced  that  the  case  can- 
not be  called  even  approximately  well.  In  still  other 
cases  the  patient  is  worn  out  with  his  general  marasmic 
condition,  and  succumbs,  or  develops  phthisis  or  some 
other  intercurrent  disorder  that  carries  him  off. 

It  is  rare  for  any  extensive  or  accurate  recollection 
of  the  incidents  during  the  attack  to  be  preserved 
by  the  patient  after  recovery.  In  any  of  the  forms 
of  confusional  insanity  he  may  have  some  partial 
reminiscences  of  the  initial  symptoms,  and  some  ob- 
scured and  perverted  recollections  of  events  during 
early  stages  of  convalescence,  often  obstinately  main- 
tained as  true  after  recovery  has  become  more  ad- 
vanced. It  is  this  class  of  patients  that  furnishes  a 
considerable  proportion  of  the  cases  that  bring  charges 
of  ill  treatment,  their  perverted  recollections  continuing 
in  their  minds  as  positive  facts,  even  long  after  their 
discharge  from  the  asylum.  While  practically  sane, 
they  still  retain  delusional  concepts  of  the  past  that 
only  gradually  wear  away,  and  often  leave  prejudices 
and  ill  feeling  toward  those  who  have  cared  for  them 
long  after  they  have  become  themselves  less  vivid  or 
have  disappeared. 

While  occasional  brief  spells  or  attacks  of  violent 
agitation  may  occur  in  all  the  forms,  and  sometimes  be 
almost  continuous  for  days  or  longer  in  the  very  acute 
types,  thus  causing  the  patients  to  be  considered  as 
violent  and  unmanageable,  actual  homicidal  tendencies 
are  rare.  Confusional  patients  are  also  not  ordinarily 
disposed  to  suicide  or  self-injury,  though  in  the  de- 
pressed cases  such  a  tendency  is  sometimes  observed. 
Like  all  the  insane,  they  may  be  reckoned  as  somewhat 
uncertain  in  these  respects,  while  not  to  be  classed  as 
especially  dangerous.     Impulsive  violence  and  suicide 


105  THE    ACQUIRED    INSANITIES. 

are  what  are  mostly  to  be  feared,  not  the  steady  con- 
tinuous tendency  observed  in  some  other  forms  of 
mental  disease. 

Prognosis. — The  prospects  of  cure  in  confusional  in- 
sanity are  variously  estimated.  Some  authorities 
make  the  prognosis  relatively  favorable,  while  others, 
like  Chaslin,  consider  it  as  dubious  at  the  best.  In  the 
different  forms  the  chances  of  recovery  vary;  in  the 
acute  form,— the  collapse  delirium,— -which  in  many 
cases  is  only  of  a  few  days'  duration,  the  patient's 
chances  are  relatively  good,  while  in  the  more  developed 
types  there  is  a  much  less  favorable  prospect.  It  often 
happens  also  that  an  apparent  incipient  convalescence 
from  the  acute  form  of  the  disorder  is  interrupted  by 
some  slight  and  apparently  trivial  cause,  and  the  pros- 
pective recovery  is  thereby  sometimes  indefinitely 
postponed.  A  woman,  for  example,  whose  case  was 
typical  in  its  way,  with  profound  mental  confusional 
symptoms,  disorientation  as  to  time  and  locality, 
numerous  shifting  hallucinations,  but  with  retained 
fair  bodily  condition,  had  rapidly  improved  and  was 
beginning  to  gradually  emerge  from  her  disordered 
mental  state,  but  with  this,  as  frequently  happens, 
her  physical  condition,  reduced  by  the  intense  stress 
and  motor  excitement  she  had  passed  through,  had 
brought  on  a  state  of  mild  mental  depression  in  which 
her  mind  seemed  to  be  slowly  realizing  matters  about 
her.  At  this  time  she  was  allowed  a  visit  from  her 
husband,  a  rough,  uneducated  man,  whose  manner  and 
behavior  to  her  on  the  occasion  were,  to  say  the  least, 
unfortunate,  according  to  the  testimony  of  the  attend- 
ants who  were  present  at  the  time.  The  result  of  his 
visit  was  an  immediate  recurrence  and  aggravation  of 
her  former  symptoms,  which  did  not  improve,  and  she 
finally  passed  into  a  secondary  stage  of  terminal  con- 
fusional dementia.  Such  cases  as  this  are  not  so  very 
infrequent,    and    their    possibility    should    always    be 


PRIMARY    CONFUSIONAL    INSANITY.  1 69 

borne  in  mind.  Apart  from  these  possibilities  the 
prognosis  of  acute  confusional  insanity  may  be  esti- 
mated largely  by  the  physical  condition  of  the  patient ; 
if  there  is  great  physical  depression,  with  a  persistence 
of  the  mental  symptoms,  in  spite  of  treatment  and 
proper  care,  it  should  be  guarded.  In  those  cases 
where  the  delirium  is  intense  and  accompanied  with 
high  temperature,  as  in  some  cases  that  closely  ap- 
proximate to  the  so-called  acute  delirium,  as  regards 
the  majority  at  least  the  chances  for  recovery  are  not 
good.  Even  in  the  less  severe  and  more  ordinary  type 
of  the  acute  form  the  danger  of  death  from  exhaustion 
or  from  some  intercurrent,  usually  pulmonary,  disorder 
is  always  to  be  kept  in  mind. 

In  the  less  acute  form  the  probabilities  of  recovery 
without  marked  mental  defect  are  rather  less  than  in 
the  acuter  type,  and  the  same  is  true  as  to  the  com- 
plete or  partial  stuporous  forms.  In  these  latter  forms, 
while  recovery  undoubtedly  occurs  in  the  majority  of 
properly  treated  cases,  the  chances  must  be  more 
diminished  according  to  the  more  intense  involvement 
of  the  mental  powers  by  the  morbid  process.  Indeed, 
we  can  say  with  Chaslin  that  in  all  forms  of  confusional 
insanity  the  prognosis  largely  depends  upon  the 
severity  of  the  symptoms,  the  extent  of  the  hallucina- 
tory and  delusional  manifestations,  and  the  physical 
condition  of  the  patient.  It  must  be  remembered  also 
that  there  is  very  likely  to  be  a  degenerative  complica- 
tion which  may  affect  the  patient's  prospects ;  a  purely 
acquired  insanity  on  a  soil  prepared  by  heredity  or 
congenital  defect  may  have  an  entirely  different  out- 
come from  that  which  would  have  occurred  in  a  normal 
individual.  What  is  true  as  to  congenital  predis- 
position is  none  the  less  so  as  to  acquired  degenerative 
defects,  which  may  also  alter  the  prognosis. 

Diagnosis. — The  diagnosis  of  acute  confusional  in- 
sanity may  present  some  difficulties.     It  has  already 


170  THE    ACQUIRED    INSANITIES. 

been  remarked  that  without  question  many  of  the  so- 
called  cases  of  mania  and  melancholia  in  the  statistics 
of  asylums  could  more  properly  be  classed  as  of  this 
type,  and  we  can  bear  personal  testimony  as  to  this 
fact.  The  non-recognition  of  the  species  has  been  in 
the  past  the  main  factor  in  this  confusion,  and  even 
yet  this  form  is  still  absent  in  many,  if  not  a  majority, 
of  asylum  tables. 

The  diagnosis  of  the  acute  form  (collapse  delirium) 
is  chiefly  to  be  made  from  mania  or  the  maniacal  stage 
of  periodic  insanity.  In  some  cases  where  mental  de- 
pression and  anxiety  complicate  this  type,  it  may  be 
confused  with  the  agitated  phase  of  melancholia.  The 
distinction  is  generally  to  be  made,  apart  from  the  fact 
of  the  disorder  following  exhausting  disease,  shock, 
etc.,  by  the  character  of  the  delirium,  the  presence 
and  predominance  of  hallucinations,  and  the  very 
marked  mental  weakness  and  retardation  of  intellectual 
action,  as  contrasted  with  mental  exaltation  of  mania 
and  the  more  systematized  and  self-accusatory  delusions 
of  agitated  melancholia.  It  is  chiefly  the  most  acute 
cases,  with  very  marked  motor  excitement  and  intense 
hallucinatory  delirium,  that  lead  to  difficulty  in  dis- 
tinguishing them  from  the  acute  maniacal  or  melan- 
cholic frenzy.  Whether  we  are  to  recognize  a  dis- 
tinct species  of  acute  delirium  or  not,  it  is  also  certain 
that  some  extreme  cases  of  acute  collapse  delirium 
fall  readily  into  this  type,  and  are  to  be  distinguished 
only  with  difficulty,  if  at  all.  Some  forms  also  of 
epileptic  pre-  and  post-convulsive  states  may  also 
simulate  this  type,  and  the  same  is  true  of  certain 
episodes  in  paretic  dementia.  In  both  these  cases  the 
general  history  and  context,  so  to  speak,  of  the  attack 
suffice,  as  a  general  rule,  to  fix  the  diagnosis.  Some 
intoxications,  alcoholic  and  others,  also  may  simulate 
collapse  delirium,  but  the  study  and  history  of  the  case 
will    commonly    clear    the    diagnosis.     It    should    be 


PRIMARY    CONFUSIONAL    INSANITY.  iyi 

remembered  that  confusional  insanity  of  this  type  may 
be  superimposed  upon  other  conditions,  and  thus  lead 
to  possible  errors;  such  accidents  will  be  more  fully 
noticed  later  on,  when  speaking  of  the  secondary  forms. 

The  more  chronic  "amentia"  is  less  likely  to  be 
mistaken  when  it  is  fully  established,  though  many 
cases,  especially  of  the  puerperal  and  lactational  forms, 
have  been  habitually  classed  as  melancholia.  Puer- 
peral melancholia  of  authors  is  indeed  very  largely 
of  this  type;  the  cases  where  the  patient  is  quiet  and 
depressed,  and  appears  to  be  suffering  from  terrifying 
hallucinations  or  delusions  which  she  cannot  compre- 
hend, while  she  does  not  speak  or  answer  questions, — 
in  short,  where  she  gives  plain  objective  evidence  of 
intellectual  confusion  and  retardation  of  ideation,  with 
physical  and  mental  depression, — are  properly  to  be 
included  in  this  type,  though  they  have  probably  been 
generally  classed  as  puerperal  melancholia. 

In  the  advanced  completely  stuporous  form  the  dif- 
ferential diagnosis  will  have  to  be  generally  from  the 
stuporous  stages  of  catatonia  and  from  that  form  of 
melancholia  known  as  melancholia  attonita,  which 
latter,  however,  so  far  as  it  exists,  is  perhaps  to  be  con- 
sidered as  a  complication  of  the  two  forms  of  insanity, 
or  as  a  superposition  of  stuporous  confusional  insanity 
upon  melancholia.  From  catatonia  the  distinction  is 
made  by  the  more  marked  physical  symptoms  of  cata- 
lepsy, and,  of  course,  if  the  history  is  obtainable,  by 
the  general  course  of  the  disorder;  from  melancholia 
with  stupor  by  the  more  pronounced  depressive  symp- 
toms than  are  generally  observed  in  simple  stuporous 
confusion. 

There  is  a  rare  form  of  stupor  that  is  sometimes  met 
with  in  those  who  have  a  very  pronounced  degenerative 
heredity,  and  which  has  received  little  notice  in  the 
text-books.  In  this  the  stupor  appears  suddenly  and 
leaves  as  quickly ;  the  bodily  condition  is  less  affected, 


172  •     THE    ACQUIRED    INSANITIES. 

while  the  mind  seems  to  be  a  blank,  the  face  perfectly 
expressionless ;  the  bodily  functions  may  be  carried  on 
almost  normally,  with  due  attention  on  the  part  of 
those  who  have  the  care  of  the  patient.  In  the  one  or 
two  cases  of  this  kind  that  we  have  seen,  the  recovery, 
like  the  onset,  was  sudden  and  complete.  These  would 
be  included  under  the  periodic  insanities  by  Kraepelin, 
resembling,  as  they  do,  the  depressive  stages  of  the 
circular  insanities ;  but  the  attack  in  the  cases  observed 
was  absolutely  isolated,  and  had,  as  far  as  known,  no 
precedent  or  subsequent  relapse  for  many  years,  though 
this  latter  may,  of  course,  be  possible  or  even  probable. 
As  far  as  the  clinical  features,  aside  from  the  physical 
symptoms,  are  concerned,  the  condition  was  identical 
with  that  of  confusional  stupor.  The  stuporous  phases 
of  some  cases  of  typical  circular  insanity  are,  of  course, 
to  be  considered  in  the  diagnosis,  as  they  may  have  a 
strong  superficial  resemblance  to  the  extreme  type  of 
confusional  insanity,  but  the  history  of  the  case  or,  that 
lacking,  continued  observation  will  reveal  the  differ- 
ence. Still,  errors  are  probable  in  this  regard,  and 
Kraepelin  emphasizes  from  his  own  experience  the 
warning  to  limit  the  diagnosis  of  acute  dementia  to 
those  cases  in  which  an  adequately  sufficient  cause  had 
produced  marked  symptoms  of  cerebral  exhaustion 
without  the  special  characteristics  of  catatonia  or  its 
peculiar  stupor.  The  age  of  the  patient  may  also  be 
of  some  aid  in  the  diagnosis  between  these  forms,  since 
catatonia,  so  called,  is  more  especially  a  disorder  of  the 
first  two  or  three  decades  of  life,  while  confusional 
stuporous  dementia  may  occur  at  any  period. 

Pathology. — The  characteristics  of  confusional  in- 
sanity, the  mental  incoherence  and  retardation,  can  be 
theoretically  explained  by  assuming  the  correctness  of 
some  of  the  latest  announced,  but  as  yet  not  fully  con- 
firmed, findings  in  the  nerve-cell  and  its  processes.  If 
the  protoplasmic  extensions  of  the  neuron  possess  the 


PRIMARY    CONFUSIONAL    INSANITY.  1 73 

powers  of  contractility  and  extension,  as  has  been 
claimed,  and  this  power  is,  as  it  would  appear,  directly 
connected  with  their  functional  activity  in  intellection, 
it  is  not  hard  to  suppose  that  disordered  connections 
in  these  might  be  associated  with  a  confused  and 
irregular  mental  action.  If  Lugaro  is  correct  in  his 
hypothesis  that  normal  cerebration  is  associated  with 
only  a  limited  number  of  contact  points,  and  that  as  a 
corollary  any  general  extension  or  contact  of  a  large 
number  of  these  processes  at  once  must  be  accompanied 
with  disordered  mental  function,  it  is  easy  to  assume  the 
occurrence  of  mental  confusion  or  delirium,  disordered 
association,  perversions  of  psychic  vision  in  the  form  of 
hallucinations — in  short,  all  the  various  symptoms  of 
acute  confusional  insanity,  including  also  the  retarda- 
tion or  embarrassment  of  intellection  in  this  way.  It 
would  also  afford  us  a  means  of  distinguishing  theo- 
retically the  pathology  of  this  condition  from  that  of 
the  intellectual  exaltation  of  simple  mania,  the  fixed 
delusional  states,  the  impulsive  and  explosive  epileptic 
conditions,  and,  in  fact,  nearly  all  the  psychic  mani- 
festations in  every  form  of  mental  disease.  Capti- 
vating, however,  as  speculations  of  this  kind  may  be, 
it  must  be  borne  in  mind  that  they  are  only  hypotheses 
as  yet,  and  even  the  fact  of  the  retraction  and  extension 
of  the  neuron  processes,  supported  as  it  is  by  the 
researches  of  Lugaro  and  the  later  ones  of  Soukhanin, 
is  not  as  yet  so  satisfactorily  established  as  to  enable 
us  to  do  anything  more  than  exercise  our  scientific 
imagination  upon  them.  The  data  reported  are  sug- 
gestive, and  for  that  reason  are  mentioned  here. 
Another  fact  which  seems  well  established  is  that  of 
the  alteration  of  the  nerve-cell  from  fatigue,  as  demon- 
strated by  Hodge,  Mann,  and  others,  and  this  also 
gives  room  for  speculation  as  to  the  underlying  phys- 
ical condition  in  the  cortex  in  confusional  insanity. 
There  is  still  to  be  considered  a  factor  that  may 


174  THE    ACQUIRED    INSANITIES. 

play  a  prominent  part  in  the  production  of  the  symp- 
toms— that  of  intoxication  by  substances  produced  in 
the  blood  and  in  the  different  tissues  by  various  morbid 
conditions,  among  them  those  of  excessive  fatigue, 
shock,  or  worry.  It  is  well  known  that  some  of  the 
normal  secretions  are  very  markedly  affected  by 
emotional  conditions ;  the  milk,  for  example,  may  thus 
become  the  cause  of  disease  in  the  infant.  Samples 
from  the  blood  of  a  fatigued  animal  can  cause  the 
symptoms  of  fatigue  when  injected  into  the  veins  of 
an  animal  at  rest  (Mosso) ,  and  while  we  know  little  as 
yet  as  to  the  exact  nature  of  this  and  other  fatigue 
poisons,  the  existence  of  such  can  hardly  be  questioned 
at  the  present  time.  The  exact  mode  of  their  opera- 
tion on  the  brain-cells  so  as  to  produce  the  sudden 
outbreak  of  mental  disease  is,  of  course,  only  a  matter 
for  conjecture,  but  there  can  be  no  more  reason  for 
doubting  their  power  thus  to  act,  provided  they  exist 
in  sufficient  quantity,  than  there  is  for  doubting  the 
similar  action  of  fever  toxins  in  giving  rise  to  the 
delirium  of  fever — a  precisely  analogous  condition. 
The  only  difference  is  that  in  the  one  case  we  have  a 
less  well-known  or  familiar  toxin  than  in  the  other. 

Leaving  aside,  however,  these  more  obscure  factors, 
we  have  one  source  of  auto-intoxication  that  is  evident 
in  many  cases,  if  not  as  originally  inducing  the  attack, 
at  least  as  maintaining  and  aggravating  the  mental 
disorder.  The  direct  connection  between  cerebral 
disturbances  and  a  disordered  condition  of  the  intes- 
tinal tract  is  illustrated  in  many  ways;  by  the  head- 
aches attending  constipation,  for  example,  and  by 
various  other  neurasthenic  symptoms  that  are  rapidly 
ameliorated  by  the  relief  of  an  overloaded  bowel. 
Bechterew  has  recently,  from  careful  clinical  examina- 
tions of  the  urine,  come  to  the  conclusion  that  intes- 
tinal auto-intoxication  plays  a  large  part  in  the  pro- 
duction of  the  symptoms  of  neurasthenia,  and  there  is 


PRIMARY    COXFUSIONAL    INSANITY.  1 75 

little  question  but  that  it  has  much  to  do  with  neuras- 
thenic melancholia,  and  also  with  the  form  of  mental 
disorder  here  under  consideration.  In  former  times 
these  effects  were  largely  attributed  to  reflex  irritation, 
and  the  theory  of  reflex  insanity  from  bowel  disorder 
was  maintained  by  Schroeder  von  der  Kolk  and  others. 
At  present  we  are  less  inclined  to  see  reflex  action,  but 
more  to  consider  the  symptoms  as  due  to  poisons  from 
retained  substances  in  the  intestinal  tract.  The  sud- 
denness of  the  relief  afforded  by  a  thorough  evacuation 
of  the  large  intestine  is  suggestive  of  a  reflex  effect,  and 
we  must  sometimes  assume  that  the  pressure  of  im- 
pacted masses  there  produces  a  temporary  toxic  action 
on  the  brain  that  is  very  largely  and  immediately 
relieved  by  their  removal.  It  not  infrequently  happens 
that  the  chief  symptoms  disappear  at  once  with  this 
relief,  but  this  subject  will  again  be  mentioned  when 
discussing  treatment.  Aside  from  this  direct  and 
temporary  intoxication  of  the  nervous  centers  by 
intestinal  accumulations,  there  are  also  probably  more 
slowly  acting  toxins  due  to  the  same  cause,  and  the 
effect  of  these  may  be  more  permanent. 

As  regards  actual  pathologic  findings  in  the  brain 
or  its  cortex,  the  results  of  investigation  have  been 
variable.  In  view  of  the  acute  type  of  the  collapse 
delirium  and  its  more  generally  favorable  prognosis, 
it  is  not  to  be  expected  that  many  reliable  data  should 
have  been  obtained  as  to  the  constant  or  usual  findings 
in  the  cortex  or  the  brain  as  a  whole.  When  death 
occurs  in  this  phase  or  stage  it  is  most  often  from  com- 
plicating acute  disorders  that  of  themselves  may  furn- 
ish lesions  independent  of  the  original  mental  disorder. 
The  macroscopic  findings  that  might  be  looked  for 
would  be,  in  the  extremely  agitated  cases,  some  degree 
of  meningeal  congestion,  which  is  perfectly  possible 
even  with  a  decidedly  marked  general  malnutrition  of 
the  brain.     So  far  there  have  been  no  very  satisfactory 


176  THE    ACQUIRED    INSANITIES. 

publications  of  any  microscopic  studies  of  the  actual 
lesions  in  these  cases  of  acute  confusional  insanit}'. 

When  the  disease  takes  on  the  hyperacute  phase  of 
acute  delirium, — and,  this  being  very  commonly  fatal, 
the  pathology  is  more  often  investigated, — the  symp- 
toms of  congestion  and  actual  inflammation  are  found 
abundantly  in  the  meninges  and  the  cortex.  There 
ma}7  also  be  marked  edema  in  these  regions,  but  the 
latter  condition  is  perhaps  more  characteristic  of  the 
findings  in  the  stuporous  cases,  in  which  it  may  be 
associated  with  cortical  anemia,  or  even,  in  long- 
continued  cases,  cortical  atrophy  (Wille) .  Von  Solder* 
in  six  cases  of  fatal  acute  delirium  which  were  ap- 
parently of  the  acute  confusional  type  found  hyperemia 
and  edema  of  the  brain  and  membranes  in  all  as  the 
chief  macroscopic  lesions.  His  cases  are  noteworthy 
in  that  he  ascribes  them  all  to  the  action  of  intestinal 
toxins,  coprostasis  having  been  a  marked  symptom, 
and  fecal  accumulations  having  existed  in  all.  With  this 
condition  there  was  a  marked  alteration  of  the  mucous 
membrane  of  the  bowel,  found  at  the  autopsy,  which 
he  believes  played  an  important  part  in  the  causation 
of  the  mental  disease.  Alzheimer,  who  recognizes 
several  different  forms  of  acute  delirium,  one  of  them 
especially  associated  with  the  exhaustion  psychoses, 
finds  in  this  latter  a  marked  alteration  of  the  ganglion 
cells  without  pronounced  tendency  to  their  breaking 
down,  a  passive  state  of  the  glia,  all  layers  of  the 
cortical  convolutions  alike  involved.  The  ganglion 
cells  were  swollen,  their  processes  showing  from  within, 
their  nuclei  showing  only  a  slight  tendency  to  degen- 
erate, the  chromatin  streaks  breaking  down  into  long 
granulations  that  soon  cease  to  take  the  stain.  Some- 
what more  advanced  morbid  changes,  he  thinks,  char- 
acterize the  intoxication  types  of  acute  delirium,  and, 
as  it  is  probable  that  in  most  cases  we  have  both  ex- 

*"Jahrb.  f.  Psych.,"  xvn.      "  Neurolog.  Centralbl.,"  1898,  924. 


PRIMARY    CONFUSIONAL    INSANITY.  1 77 

haustion  and  intoxication  as  causal  factors,  it  is  prob- 
able that  all  these  findings  may  be  present  in  these 
hyperacute  cases  of  confusional  insanity.  In  the 
polyneuritic  forms,  if  the  type  of  insanity  first  noticed 
by  Korsakoff  is  to  be  included  to  any  extent  under  this 
head,  we  may  have  neuritic  lesions  in  the  brain  as  well  as 
in  the  peripheral  nerves.  Nissl,  Hoch,  and  Turner  have 
described  a  peculiar  pigmented  condition  of  the  larger 
cortical  motor  cells  which  the  latter  author  considers 
characteristic  of  this  type  of  delirium.  Whitwell  * 
considers  stupor  to  be  due  to  disproportioned  relation 
of  blood  in  the  brain.  He  says  that  in  these  cases  we 
often  find  a  circulation  disproportioned  to  the  area, 
small  heart,  narrow  aorta,  etc.,  and  in  one  case  of 
intermittent  stupor  he  observed  transient  spasm  of  the 
peripheral  vessels. 

Some  observers  have  noted  the  state  of  the  blood  in 
exhaustion  psychoses,  and  so  far  as  data  have  been 
obtained,  it  would  appear  that  the  most  notable  change 
is  in  the  decrease  of  the  red  corpuscles,  that  of  the  leu- 
cocytes and  of  the  hemoglobin  being  much  less  marked. 
This  anemia  does  not  appear  early,  according  to  Batty 
Tuke  f ;  certainly  not  before  the  end  of  the  prodromal 
period,  and  often  not  till  later.  It  may,  therefore, 
probably  be  accepted  as  a  result  of  the  mental  disorder, 
rather  than  as  a  cause,  at  least  in  those  cases  where 
this  is  true.  There  is  no  doubt,  however,  that  a 
morbid  condition  of  the  blood  reacts  on  the  nervous 
disorder,  as  Mosso  has  shown,  by  carrying  fatigue 
toxins,  for  example,  and  it  may  in  some  instances  have 
a  more  important  etiologic  relation  to  the  disease,  or 
its  continuance  and  aggravation,  than  is  here  indi- 
cated. It  is  hard  to  estimate  the  exact  relative  impor- 
tance of  pathologic  facts  in  mental  disease ;  and  while 
it  is  easy  to  say  that  the  disturbance  is  due  to  fatigue 

*  "Brain,"  spring,  1895. 

t" Insanity  of  Overexertion  of  the  Brain,"  p.  42. 

12 


178  THE    ACQUIRED    INSANITIES. 

or  to  brain  stress  of  one  kind  or  another,  that  does  not 
tell  the  whole  story.  The  action  of  toxins  can  never 
be  excluded  in  these  cases,  from  the  nature  of  things, 
and  it  may  underlie  even  the  obvious  lesions  of  over- 
exertion. 

Treatment. — The  principal  facts  to  be  borne  in  mind 
in  the  treatment  of  confusional  insanity  are  that  we 
have  to  do  with  a  condition  of  brain  exhaustion  and 
malnutrition,  and  also  that  there  is,  besides  this,  in 
many  if  not  in  all  cases  an  element  of  auto-intoxication 
to  be  also  taken  into  account.  The  indications,  there- 
fore, are,  first,  to  restore  nutrition,  to  secure  rest,  and 
to  eliminate  whatever  toxin  factors  there  may  be  that 
are  actively  or  otherwise  assisting  in  the  perpetuation  of 
the  disordered  conditions  in  the  brain.  More  than  in 
almost  any  other  type  of  mental  disease  the  patients 
are  to  be  considered  and  treated  as  veritably  sick 
individuals,  and  the  methods  of  care  and  nursing  ap- 
plicable to  such  to  be  applied.  One  of  the  first  things 
to  be  attended  to  is  to  secure  as  far  as  possible  mental 
quiet  and  rest,  and  where  it  is  possible  this  can  often 
be  best  attained  by  keeping  the  patient  in  bed.  In 
certain  especially  excited  cases  of  acute  "collapse 
delirium"  this  maybe  difficult,  or  otherwise  imprac- 
ticable, but,  as  a  rule,  it  is  certainly  advisable.  This 
course  requires  the  constant  attention  of  one  or  more 
nurses ;  its  cost,  therefore,  may  put  it  out  of  the  reach 
of  many,  but  it  is  the  only  plan  by  which  home  treat- 
ment of  these  cases  is  really  practicable  or  easy.  In 
asylums,  especially  those  of  a  private  character,  it 
ought  to  be  the  rule  in  these  cases,  and  should  be  con- 
tinued for  such  a  time  as  the  excitement  and  confusion 
are  marked  and  the  patient's  nutrition  suffers.  The 
moral  effect  of  the  treatment  is  good,  and  if  due  care 
is  exercised  against  the  formation  of  bed-sores,  and 
to  secure  proper  cleanliness,  there  are  no  possible 
objections   to   the   method   where   the   attendance   is 


PRIMARY    CONFUSIONAL    INSANITY.  1 79 

sufficient  to  make  it  possible.  There  is  sometimes 
a  difficulty,  it  is  true,  in  our  large  asylums  in  securing 
enough  skilled  attendance  for  this  purpose;  the  per 
capita  cost  must  be  kept  down  to  the  appropria- 
tions, and  taxpayers  cannot  always  be  made  to  see  the 
necessity  of  such  expense.  It  is  fortunate,  therefore, 
that  a  large  proportion  of  the  cases  will  recover  under 
other  methods  of  treatment;  the  "rest  in  bed"  system, 
though  the  best,  is  not  always  essential;  a  patient 
whose  physical  and  mental  condition  makes  special 
attendance  requisite  to  enforce  the  bed  treatment  has 
still  generally  the  vigor  and  vitality  to  improve  under 
other  measures  judiciously  employed,  but  there  is  little 
doubt  that  some  cases  that  succumb  to  so-called 
maniacal  exhaustion  could  be  saved  by  this  means. 

The  question  of  bed-sores  is  sometimes,  though  rarely, 
a  serious  one ;  they  are  favored  by  the  general  condition 
of  malnutrition  of  the  patient,  and  we  have  seen  them 
form  a  very  troublesome  complication  almost  from  the 
very  beginning  of  the  attack  in  a  patient  who  after 
several  months  made  an  apparently  complete  recovery. 
It  is  in  only  a  small  percentage  of  these  cases  that  they 
appear  at  all,  but  their  occurrence  is  favored  rather 
than  otherwise  by  the  "rest  in  bed"  treatment,  unless 
care  is  used  to  prevent  them.  With  the  rest  and  quiet 
obtained  by  the  bed  treatment,  three  other  indications 
are  to  be  met — the  securing  of  sleep,  nourishment  of 
the  patient,  and  attention  to  the  state  of  the  excre- 
tions. It  is  a  good  plan  to  commence  the  bed  treat- 
ment with  a  thorough  cleaning  out  of  the  lower  bowel 
by  enema,  a  warm  bath  (temperature  930  to  950  F.), 
which  may  be  prolonged  for  half  an  hour  or  more  if 
thought  advisable,  and  a  full  meal  of  milk  and  eggs. 
This  treatment  will  very  often  be  followed  by  a  natural 
sleep,  and  the  patient's  convalescence  may  date  its 
beginning  from  the  awakening.  The  prolonged  warm 
bath,    continued    even     for     hours,    is     an    excellent 


ISO  THE    ACQUIRED    INSANITIES. 

sedative,  and  will  help  to  quiet  excited  cases.  The 
moist-pack  is  also  useful  in  some  of  these  cases,  but  its 
overuse  for  this  purpose  has  created  a  prejudice 
against  it  in  some  countries,  which  has  been  transferred 
here,  where  the  practice  has  not  been  so  much  abused. 
Usually  the  warm  bath  alone  will  quiet  excitement, 
and  even  the  acute  cases,  which  are  here  specially 
considered,  of  confusional  insanity  are  generally  docile 
enough  to  be  easily  managed  and  quieted  so  as  to 
submit  readily  to  the  bed  treatment  and  the  control 
of  a  skilled  nurse.  If  the  excitement  is  excessive, 
cold  compresses  to  the  head  may  also  be  useful  with 
the  warm  bath. 

In  a  few  exceptional  cases  where  the  physical  powers 
of  the  patient  are  very  little  reduced  and  the  motor 
excitement  excessive,  with  tendencies  to  violence  on 
account  of  the  nature  of  the  hallucinations  or  delusions, 
it  may  be  difficult  to  apply  the  rest  treatment,  and 
isolation  or  seclusion  may  be  necessary  for  a  time. 
Such  cases  may  test  the  physician's  ingenuity  and 
resources,  but  they  are  rare,  and  closely  approximate 
some  epileptic  conditions,  and,  like  them,  are  seldom 
very  prolonged. 

The  feeding  of  the  patient  may  often  present  some 
difficulties;  the  patient  has  frequently  no  desire  for 
food,  and  may  resist  when  it  is  offered.  When  patience 
and  tact  on  the  part  of  the  attendant  completely  fail 
to  induce  him  to  allow  himself  to  be  fed  by  the  ordinary 
methods,  artificial  feeding  must  be  resorted  to,  and 
this  ought  not  to  be  put  off  too  long,  as  full  nutrition 
and  even  hypernutrition  is  needed  in  these  cases.  In 
the  hyperacute  delirious  cases  this  is  especially  im- 
portant. It  often  happens  in  ordinary  acute  or  sub- 
acute confusional  insanity  that  one  or  two  feedings 
with  the  tube  will  be  all  that  is  required,  and  that  the 
patient  will  readily  feed  himself  or  let  others  feed  him 
after  one  or  two^such  operations.     It  may  be  advisable 


PRIMARY    CONFUSIONAL    INSANITY.  151 

also  to  use  washings  out  of  the  stomach,  and  to  care- 
fully watch  its  condition  as  to  hyper-  or  hypo-acidity. 
This,  however,  is  not  always  necessary,  and  in  most 
cases  the  digestion,  though  disordered,  rapidly  im- 
proves under  proper  care. 

While  this  is  being  done,  attention  must  also  be 
given  to  the  state  of  the  excretions,  especially  the 
bowels.  The  condition  in  which  these  are  sometimes 
found  in  patients  who  have  been  neglected  in  this 
respect  can  hardly  be  readily  imagined  by  any  one  who 
has  not  seen  the  cases.  In  some  instances  the  rectum 
has  been  found  full  of  impacted  hardened  masses  that 
required  what  might  be  called  extensive  mining  opera- 
tions to  relieve  the  condition,  while  the  whole  digestive 
tract  from  the  pharynx  down  appeared  to  be  in  a 
generally  offensive  state.  Even  after  mechanical 
relief  had  been  obtained  with  great  trouble,  much 
difficulty  has  been  experienced  in  securing  proper 
action  of  the  bowels  with  any  ordinary  laxative  or 
purgative  agents,  and  days  have  elapsed  before  it  could 
be  adequately  obtained.  The  relief  to  the  symptoms, 
however,  from  a  thorough  cleaning-out  of  even  the 
lower  bowel  is  often  most  striking.  Reference  has 
already  been  made  to  a  case  of  a  man  whose  attack  was 
due  to  overwork  and  excitement,  and  who  wandered 
from  home,  but  still  preserved  some  notions  of  locality, 
and  once  or  twice  in  his  more  lucid  states  had  sent 
incoherent  messages  to  his  family.  When  finally  found 
by  them,  he  was  in  a  semi-stuporous  condition,  and  the 
only  utterance  that  could  be  called  out  from  him  was 
"  I  am  tired,"  or  some  similar  expression.  A  thorough 
purgation  made  a  different  man  of  him  at  once;  he 
recognized  his  wife  and  friends,  and  while  not  at  once 
appreciating  all  his  surroundings,  and  still  preserving 
a  certain  degree  of  confused  mentality,  he  seemed  at 
once  advanced  a  long  way  on  the  road  to  recovery. 
Other  similar  cases  could  probably  be  reported  by  any 


182  THE    ACQUIRED    INSANITIES. 

experienced  alienist.  It  is  not  safe  to  assume  because 
there  is  apparently  a  daily  evacuation  in  these  patients 
that  there  is  not  a  fecal  stasis  and  poisoning  from 
intestinal  toxins.  The  physician  must  assure  himself 
that  such  is  not  the  case.  Of  course,  drastic  cathartics 
are  not  required  or  useful,  but  the  thorough  emptying 
of  the  intestine  from  any  long-retained  matter  is  a 
necessity.  The  use  of  some  intestinal  antiseptic  is  also 
often  advisable  in  these  cases. 

The  use  of  sleep-producing  or  quieting  drugs  is  con- 
demned by  some  authorities,  but  their  cautious,  judi- 
cious use  may  be  required  in  some  cases,  always,  how- 
ever, bearing  in  mind  that  the  necessity  is  an  excep- 
tional one,  and  avoiding  any  steady  dependence  upon 
them.  The  best  to  use  in  these  acute  (collapse  de- 
lirium) cases  are  the  less  dangerous  ones — chloralamid, 
paraldehyd,  sulphonal,  and  in  some  cases  the  bromids 
in  moderate  doses,  and  with  careful  observation  of 
their  effects.  In  many  cases  a  mild  stimulating  dose 
of  alcohol  in  milk-punch,  or  a  glass  of  beer,  will  be 
effective.  In  the  ' '  amentia ' '  type  of  cases  these  nar- 
cotics are  more  often  indicated,  but  in  all  cases  the 
physical  state  of  the  patient  should  be  considered,  and 
depressing  agents  avoided  whenever  the  condition  of 
the  vital  powers  is  lowered,  as  is  so  frequently  the 
case  in  these  patients.  In  the  hyperacute  delirious 
confusion  the  chief  indication  is,  of  course,  to  support 
the  patient's  strength  and  use  hyperalimentation  as  far 
as  practicable.  In  stuporous  cases  much  depends 
upon  careful  nursing,  cleanliness,  good  feeding,  fresh 
air,  attention  to  the  stomach  and  bowels,  and  to 
proper  hygienic  conditions.  Tonics  are  often  valu- 
able, especially  in  the  convalescent  stages,  and  as 
such  quinin  and  strychnin  have  been  especially  rec- 
ommended. Of  course,  if  anemia  exists,  iron  should 
be  given,  with  perhaps  small  doses  of  arsenic.  It  is 
needless,  however,  to  go  over  the  list  of  drugs,  as  each 


SECONDARY    CONFUSIONAL    INSANITY.  183 

case  must  be  studied  separately,  and  the  appropriate 
medication  selected  on  the  same  principles. 

The  moral  treatment  of  these  cases  is  simple,  and  is 
generally  confined  to  the  convalescent  stages.  Con- 
fusional  cases,  with  only  rare  exceptions  when  the 
motor  excitement  is  excessive,  or  the  hallucinations 
particularly  terrifying,  are  generally  docile  and  readily 
controlled  by  tactful  attendants.  They  are,  while  the 
disorder  is  at  its  height,  hardly  able  to  appreciate 
their  surroundings,  and  any  moral  treatment  must  be 
in  the  influence  exercised  upon  them  by  judicious  over- 
sight and  management.  It  is  in  the  remissions  and 
in  convalescence  that  special  care  should  be  taken  to 
prevent  anything  that  aggravates  their  condition,  and 
this  will  depend  largely  upon  the  good  judgment  of 
physician  and  attendants ;  it  is  impossible  to  lay  down 
special  rules.  In  the  stuporous  cases  something  can 
sometimes  be  attempted  in  the  way  of  arousing  the 
attention  of  the  patient,  and  as  signs  of  improvement 
appear,  a  carefully  adjusted  course  of  gentle  exercises 
may  be  begun,  always,  of  course,  with  close  observa- 
tion of  the  patient's  condition,  and  special  care  to 
avoid  overexertion  or  fatigue.  In  all  forms  the  great- 
est care  should  be  exercised  during  convalescence  to 
guard  against  overfatigue  and  all  disturbing  influences 
of  every  kind. 

SECONDARY  CONFUSIONAL  INSANITY. 

It  has  been  already  remarked  that  confusional  in- 
sanity may  occur  as  a  complication  in  many  other 
forms  of  mental  disease — or,  as  it  were,  superimposed 
upon  them.  Marandon  de  Montyel  has,  indeed,  claimed 
that  this  be  considered  only  as  a  symptom,  analogous 
to  delirium  in  fever,  and  that  it  only  exceptionally 
appears  as  a  simple,  uncomplicated  disorder  by  itself. 
This,  however,  is  only  a  partial  view  of  the  subject, 
and  is  probably  due  to  a  failure  to  recognize  this  type 


184  THE    ACQUIRED    INSANITIES. 

in  many  instances  from  other  forms  of  mental  disorder. 
Del  Greco,  in  an  extensive  discussion  of  the  subject, 
divides  confusional  insanity  into  five  great  classes, 
according  to  the  amount  of  degenerative  taint  existing, 
the  first  of  which,  and  in  part  also  the  second,  comprise 
the  disorder  as  here  considered.  The  remainder  may 
be  considered  as  complicating  or  secondary  types,  on  a 
basis  of  already  existing  mental  defect  or  disease.  It 
is  not  hard  to  understand  why  patients  already  men- 
tally disordered  should  be  liable  to  confusional  ex- 
acerbations ;  a  brain  already  morbid  might  well  break 
down  under  less  strain  than  would  be  required  to 
seriously  affect  a  normal  one.  We  may  even  consider 
the  extreme  stage  of  maniacal  excitement,  as  Chaslin 
points  out,  as  a  sort  of  confusional  exacerbation  in 
which  the  ideas  tumble  over  each  other,  and  the  intel- 
lect cannot  keep  track  of  them,  of  the  sensory  impres- 
sions thus  giving  rise  to  the  numerous  illusions  and 
even  hallucinations  of  that  condition.  In  secondary 
dementia  from  any  cause  the  cerebrum  is  a  weakened 
organ,  and  therefore,  we  may  naturally  suppose,  is 
more  liable  to  the  effects  of  any  overstrain  or  toxin. 
The  same  is  true  of  the  less  chronic  insanities,  in 
epilepsy  and  in  the  already  diseased  cortex  of  paretic 
dementia,  in  which  the  hyperacute  form  of  delirious 
confusion  is  not  infrequently  a  fatal  complication. 
These  facts,  however,  do  not  justify  us  in  following 
Marandon  de  Montyel  in  assuming  that  confusional 
insanity  is  only  a  symptom  and  not  an  independent 
specific  form  of  mental  disease.  It  may  occur  in  im- 
beciles or  in  paranoiacs,  but  it  is  not  therefore  a  symp- 
tom of  imbecility  or  paranoia,  and  we  can  say  with  no 
more  justice  that  it  is  merely  a  symptom  of  any  other 
form  of  disease  of  the  brain  or  the  mind.  General 
paresis  may  also  be  superimposed  upon  these  conditions, 
but  we  do  not  therefore  call  it  a  symptom  of  them. 


CHAPTER  XI. 
MELANCHOLIA. 

Melancholia  is  a  form  of  mental  derangement 
characterized  especially  by  more  or  less  profound  de- 
pression, with  retardation  of  intellection,  with  retained 
consciousness,  developing  in  its  progress  secondarily 
delusive  ideas,  chiefly  of  self -accusatory  nature,  some- 
times also  extreme  agitation,  and  often  with  intensely 
suicidal  and  homicidal  tendencies. 

In  its  mildest  forms  melancholia  consists  of  simple 
depression  with  often  vague  feelings  of  unworthiness 
and  wrong-doing,  but  without  any  real  intellectual 
defect;  it  is  in  this  stage  a  purely  emotional  disorder. 
The  feelings  of  unworthiness  are  not  delusions,  because 
the  patient  has  no  real  faith  in  them;  he  appreciates 
their  unreasonableness,  and  resists  them  to  the  best  of 
his  ability.  In  this  form  it  is  probably  the  most  com- 
mon of  all  mental  derangements,  and  as  a  transient 
experience  is  known  to  a  very  large  proportion  of 
rational  individuals.  An  ordinary  severe  attack  of  the 
"blues,"  the  manifestation  in  consciousness  of  a  dis- 
ordered digestion  or  a  temporary  toxemia  from  con- 
stipation, is  really  nothing  less  than  an  instance,  short 
and  fleeting,  of  this  mildest  type  of  melancholia. 
When,  as  the  result  of  original  predisposing  weakness, 
or  the  changes  incident  to  failing  powers  with  advanc- 
ing age,  or  as  the  result  sometimes  of  special  toxic  or 
other  influences  seriously  affecting  the  system  and  the 
action  of  the  emotional  controlling  organs  of  the  nerve- 
centers,  this  condition  becomes  more  or  less  permanent, 
we  have  melancholia.  There  are  many  persons  living 
in  the  community  and  taking  a  part  in  active  life  who 


l86  MELANCHOLIA. 

have  been  and  are  subject  to  attacks  of  emotional  de- 
pression under  favorable  conditions,  and  yet  whose  dis- 
order, though  temporary  and  subject  to  repetitions, 
cannot  be  considered  periodic,  as  it  always  is  the  result, 
in  their  opinion,  of  some  adequate  physical  cause ;  they 
are  psychic  neuralgics,  and,  as  in  the  case  of  the  purely 
physical  neuralgia,  the  disorder  is  only  the  expression 
of  a  nervous  weakness,  occasionally  revealing  itself 
under  conditions  of  special  stress.  It  is  a  question,  in- 
deed, whether  or  not  we  can  speak  of  a  quasi-physiologic 
melancholia  of  short  duration,  occurring  sometimes 
under  such  conditions.  Some  phases  of  religious  ex- 
perience in  certain  individuals  would  almost  seem  to 
justify  the  term,  and  they  may  occur  in  individuals 
once  in  a  lifetime  and  in  those  who  cannot  be  accused 
of  any  special  mental  weakness  or  failure. 

While  pure  melancholia  is  largely  a  disorder  of 
advanced  life,  we  cannot  follow  Kraepelin  in  classing  it 
amongst  the  senile  mental  disorders.  It  may  and 
often  does  occur  in  youth,  and  in  the  prime  of  life.  It 
is  probably  because  it  most  frequently  appears  in  its 
milder  form  at  these  ages,  and  does  not  progress  to  a 
stage  that  disables  the  patient  from  following  his  usual 
occupation,  or  to  apparently  require  asylum  treatment, 
that  they  are  very  commonly  overlooked,  and  un- 
recognized. Including  these  cases,  melancholia  is  one 
of  the  commonest,  if  not  the  commonest,  forms  of 
mental  disorder. 

Etiology. — The  chief  causes  of  melancholia  besides 
predisposition  are  sudden  emotions,  such  as  grief  and 
chagrin,  shock,  long-continued  depressing  surround- 
ings, especially  if  associated  with  defective  or  insuffi- 
cient nutrition,  overwork  under  the  same  conditions, 
and  intoxications  of  various  kinds,  especially  if  due 
to  retained  waste  products  in  the  system.  The 
changes  in  the  brain  from  beginning  old  age  also  seem 
to  specially  favor  its  occurrence,  hence  its  inclusion  by 


mm 

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SUP  »W.     J| 

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aS* 

ETIOLOGY.  187 

Kraepelin  among  the  insanities  of  senility.  It  is 
rather  more  common  amongst  women  than  amongst 
men,  and  amongst  the  northern  than  the  southern 
peoples,  according  to  some  investigators.  It  seems 
probable,  for  some  reasons,  that  it  is  more  common  in 
civilized  and  highly  cultured  communities  than  are 
some  other  types  of  acute  insanity,  and  its  frequency 
is  on  the  increase,  as  it  is  one  of  the  more  direct  re- 
sults of  the  stress  of  modern  civilization. 

Nostalgia,  or  homesickness,  in  its  aggravated  form 
may  be  considered  as  a  special  type  of  melancholia, 
which,  without  self-accusatory  delusions,  as  a  rule, 
tends  to  intense  depression  and  sometimes  to  suicide. 
It  is  caused  by  removal  from  home  scenes  and  by 
monotonous  or  unaccustomed  surroundings,  and  is 
common  among  fresh  recruits  in  armies ;  usually  it  has 
for  its  subjects  those  of  rather  limited  intellectual 
resources,  and  of  narrow  previous  experience.  De- 
pressing and  unusual  environments  are  generally  asso- 
ciated as  causes,  and  it  is  said  to  be  specially  frequent 
in  mountaineers  removed  from  their  native  hills  and 
transferred  to  a  plain  or  level  country.  Something 
approaching  it  is  also  experienced  by  those  who  have 
always  lived  in  a  level  country  and  are  transferred  to 
deep  valleys,  which  have  a  directly  depressing  influ- 
ence upon  them. 

Melancholia  from  toxic  agents  is  probably  more 
common  than  is  supposed,  but  it  is  likely  to  be 
temporary.  The  action  may  be  directly  on  the  cir- 
culation of  the  brain,  but  possibly  more  often  on  the 
nerve-cells  affecting  their  nutrition.  If  the  exposure 
to  the  toxic  action  has  been  brief,  as  in  the  case 
of  surgical  anesthesia,  for  example,  which  has  been 
known  to  produce  this  form  of  mental  derangement, 
the  disorder  is  likely  to  be  temporary.  One  case  was 
observed  by  us  in  which  the  use  of  nitrous  oxid  for  the 
removal  of  a  tooth  caused  a  marked  and  peculiar  type 


155  MELANCHOLIA. 

of  depression,  lasting,  however,  only  twenty-four  hours. 
Long-continued  exposure  to  toxic  influences,  as  in  lead- 
poisoning,  may,  on  the  other  hand,  give  rise  to  a  more 
permanent  and  serious  form. 

It  is  worth  remarking  here  that  melancholic  mental 
derangement  is  probably  the  most  universal,  as  well 
as  the  most  frequent  type;  it  is  not  confined  to  the 
human  species,  but  has  been  observed  in  the  domestic 
animals,  and  doubtless  also  may  exist  among  animals 
in  their  natural  state.  We  have  known  of  the  case  of 
a  Newfoundland  dog  taken  on  a  long  sea-voyage, 
and  when  many  weeks  out  of  sight  of  land  became 
depressed  and  unnatural  in  its  manner,  and  finally 
deliberately  jumped  overboard  and  drowned,  a  case 
apparently  of  melancholic  suicide.  Stories  of  animals 
dying  of  grief  at  the  loss  of  their  mates  or  their  masters 
are  common  enough,  and  need  not  be  too  freely  dis- 
credited. 

Symptoms. — The  beginnings  of  melancholia  are 
usually  insidious  or  at  least  gradual.  There  may  be 
a  history  of  failing  health  for  weeks,  months,  or  even 
a  year ;  it  is  seldom  the  case  that  it  begins  abruptly  in 
the  pure  form  of  the  disorder.  The  patient  generally 
complains  of  insomnia,  the  sleep  is  broken  by  troubled 
thoughts,  and  if  not  specially  limited  as  to  time  it  is 
interrupted  by  unpleasant  dreams,  and  is  unrefreshing. 
The  subject  often  distresses  himself  needlessly  with 
worries  about  business  or  family  matters;  there  are 
spells  of  more  or  less  intense  depression,  and  often  the 
unreasonableness  of  these  is  appreciated  by  the  indi- 
vidual, but  he  cannot  rid  himself  of  his  morbid  feelings. 
A  not  uncommon  phase  or  feature  of  these  spells  is  a 
feeling  of  wrong-doing  or  guilt,  that  becomes  more 
prominent  later,  and  is  the  origin  of  the  self-accusations 
that  form  so  frequent  and  prominent  a  characteristic 
of  the  fully  developed  disorder.  These  spells  become 
gradually  more  frequent  till  they  predominate  in  the 


SYMPTOMS.  189 

mental  life  and  full-fledged,  melancholia  exists.  Dur- 
ing all  this  time  the  intellect  seems  clear,  the  patient 
still  appreciates  his  surroundings,  and  may  seek  treat- 
ment or  advice  to  ward  off  what  he  recognizes  as  ad- 
vancing disease,  but  is  himself  impotent  to  prevent. 

On  the  physical  side  there  are  also  symptoms;  in 
most  cases  there  is  more  or  less  constipation,  often  to 
a  very  marked  degree;  the  stomach  is  likely  to  be 
deranged,  the  appetite  fails,  and,  finally,  there  is  a 
disgust  for  food,  the  patient  will  not  eat  or  does  so 
without  relish  and  regularity.  A  very  marked  degree 
of  general  gastric  disturbance  is  frequently  observed ; 
loaded  bowels,  coated  tongue,  and  foul  breath,  which 
become  more  aggravated  as  the  disease  progresses, 
are  not  infrequently  observed.  In  other  cases,  how- 
ever, while  there  may  be  disturbance  of  or  lack  of 
sleep  and  some  tendency  to  constipation,  the  physical 
symptoms  at  this  stage  are  not  pronounced ;  the  depres- 
sion is,  as  it  were,  remittent  or  even  intermittent;  the 
patient  goes  about  his  ordinary  pursuits,  it  may  be 
quite  unsuspected  of  any  mental  derangement  by 
those  who  meet  or  associate  with  him.  Neverthe- 
less, his  mental  condition  is  at  times  that  of  intense 
depression,  and  these  cases  are  often  the  most  danger- 
ous as  regards  suicide  or  even  homicide,  because  they 
are  the  least  suspected.  In  some  cases  the  patient's 
condition  may  continue  in  this  type,  and  form  the  so- 
called  subacute  melancholia  or  melancholia  with  con- 
sciousness, the  mental  disturbance  never  passing 
beyond  the  stage  of  simple  depression,  and  the  reason- 
ing powers  and  self-control  being  largely  retained. 
These  lighter  attacks  of  melancholia  are  probably  the 
most  frequent  of  all  its  types,  the  patient  only  now  and 
then  coming  under  the  observation  of  the  alienist,  or 
even  of  the  general  practitioner,  except  it  may  be  for 
some  bodily  ailment.  The  writers  are  inclined  to  be- 
lieve that  some  cases  even  pass  into  a  chronic  form  of 


190  MELANCHOLIA. 

mild  general  depression  after  these  attacks,  in  which 
the  symptoms  are  so  little  pronounced  that  for  years 
the  individual  may  simply  be  regarded  as  normally 
low-spirited  and  possibly  a  little  slow  or  queer  mentally 
by  his  friends,  who  from  familiarity  overlook  his  pecu- 
liarities. 

In  some  instances,  and  in  young  or  middle-aged,  as 
well  as  in  elderly  people,  the  onset  is  more  rapid ;  it  may, 
indeed,  be  sudden,  after  a  severe  moral  shock  or  an 
acute  illness.  In  these  cases,  however,  we  have  to  look 
out  for  a  degenerative  taint,  and  to  consider  the  pos- 
sibility of  the  existence  of  periodic  or  circular  insanity. 
It  is  beyond  doubt,  however,  that  there  may  be  in- 
stances of  pure,  simple  melancholia,  generally  of  the 
milder  depressive  type,  that  arise  from  sudden  shock, 
grief,  etc. 

After  the  incipient  stage  is  passed  and  full-fledged 
melancholia  has  taken  its  place,  the  symptoms  have 
changed.  The  predominant  picture  now  is  a  fixed 
intense  depression,  with  a  decidedly  delusive  tendency ; 
the  patient's  judgment  and  mental  powers  have  given 
way;  he  surrenders  to  his  morbid  feelings;  his  whole 
mind  is  concentrated  on  his  mental  distress,  which  he 
shows  in  his  facial  expression  and  bodily  attitudes. 
The  vague  feeling  of  having  done  something  wrong  has 
developed  into  a  belief,  a  conviction  that  his  soul  is 
lost,  that  all  the  world  knows  his  unworthiness ;  he 
finds  in  the  memories  of  his  past  life  what  is  to  him 
ample  proof  of  his  delusions,  and  in  what  he  observes 
in  those  around  him  evidence  that  they  also  share  his 
knowledge.  Everything  is  wrong  with  him,  and  he  has 
wronged  those  nearest  and  dearest  to  him ;  his  punish- 
ment has  already  begun  upon  earth,  and  is  to  continue 
through  eternity ;  he  is  incapable  of  ever  feeling  pleasure 
or  comfort  again.  With  this  comes  the  idea  of  suicide 
and  self-torture.  One  melancholiac  wants  melted  lead 
poured  down  his  back,  and  tries  to  gouge  out  his  eyes ; 


SYMPTOMS.  191 

another  picks  out  the  most  dangerous  and  violent 
patient  in  his  ward  and  endeavors  to  irritate  him  into 
making  an  attack  upon  him.  With  all  this,  and  a 
certain  slowness  and  embarrassment  of  thought,  there 
may  be  in  all  matters  outside  of  his  morbid  feelings 
and  delusions  quite  a  normal  state  of  intellection,  and 
sometimes  brief  diversions  of  the  ideas  may  be  brought 
about  even  in  pronounced  melancholia.  It  is  not  in- 
frequently observed  that  desperate  melancholiacs  have 
still  a  sense  of  humor,  and  can  see  the  point  of  a  joke  as 
quickly  as  others.  While  the  dominant  note  in  the 
delusions  of  most  of  this  class  is  a  quasi-religious  one, 
the  delusions  of  unworthiness  generally  relating  to 
imagined  sins,  that  of  having  committed  the  unpardon- 
able sin  being  one  of  the  most  common,  there  are  some- 
times variations  from  this ;  in  some  the  delusions  may 
be  of  a  hypochondriacal  type,  and  we  have  known  of  at 
least  one  aberrant  case  in  which  the  whole  tendency  of 
thought  was  distinctly  irreligious.  The  patient  was 
most  of  the  time  in  a  sort  of  frenzy,  walking  around  and 
cursing  himself  in  the  most  blasphemous  and  obscene 
manner.  He  could  be  diverted  momentarily,  but  would 
return  to  his  ravings  immediately.  In  this  case  the 
depression  was  of  a  peculiar  type,  but  it  could  hardly 
be  classed  as  anything  but  a  sort  of  melancholic 
frenzy,  and  it  was  accompanied  with  many  of  the 
typical  psychic  symptoms,  which,  however,  soon  dis- 
appeared under  treatment,  and  the  patient  made  a 
good  recovery. 

The  excessive  motor  agitation,  melancholic  frenzy, 
or  melancholic  agitation  may  sometimes  appear  at  this 
stage,  and  forms  a  peculiarly  distressing  syndrome, 
though  its  significance  is  not  always  bad.  Patients  of 
this  type  are  possibly  no  more  dangerous  than  others, 
and  equally  liable  to  recover.  They  are  in  constant 
motion,- sometimes  repeating  over  and  over  the  same 
complaint.     Their  distress  is  more  expressed,  but  not 


192  MELANCHOLIA. 

necessarily  felt  more  intensely.  The  case  is  somewhat 
different  with  those  in  whom  the  quiet  but  extreme 
depression  is  interrupted  by  sudden  brief  spells  of 
violence,  in  which  they  may  be  dangerous  to  them- 
selves and  others.  The  danger  is  greater  in  these  cases 
because  it  is  unexpected;  the  attacks  may  be  semi- 
automatic and  uncontrollable,  or  they  may  be  deliber- 
ately designed  by  the  patient  as  affording  in  some  way 
a  relief  from  his  painful  feelings. 

Hallucinations  occur  in  the  advanced  stages  of 
melancholia,  but  they  are  neither  so  frequent  nor  so 
characteristic  of  this  type  of  insanity  as  they  have  been 
considered.  In  many  cases,  we  think,  they  have  been 
credited  to  it  when  they  really  occurred  in  a  depressed 
form  of  confusional  insanity.  It  is  only  in  the  extreme 
phases  of  the  disorder  that  they  occur,  when  the  delu- 
sive conceptions  have  dominated  the  mental  life  so 
fully  that  the  patients  begin  to  seek  confirmation  of 
them  in  the  evidence  of  their  senses,  and  in  many 
melancholiacs,  at  least,  the  so-called  hallucinations  are 
only  perverted  recollections  of  misinterpreted  percep- 
tions that  were  not  at  the  time  of  their  actual  occur- 
rence really  hallucinations.  The  patients  say  they 
have  heard  voices  accusing  them  or  confirming  their 
self -accusations,  but  in  many  cases  the  idea  is  really 
the  father  of  the  thought.  The  occurrence  of  dreams, 
especially  the  semi- waking  ones,  may  also  be  invoked 
to  account  for  some  of  these  sense  deceptions  in 
melancholia.  In  comparatively  few  pure  cases  of 
melancholia  have  we  been  able  to  observe  what  ap- 
peared to  us  as  evidence  of  actual  existing  hallucina- 
tions, such  as  are  so  frequent  and  characteristic  of 
confusional  or  paranoiac  derangement.  That  they 
sometimes  occur  may  be  admitted  as  undeniable,  but 
that  they  are  common  or  characteristic  of  this  special 
form  of  mental  derangement  cannot,  we  believe,  be 
correctly  asserted. 


SYMPTOMS.  193 

There  is  commonly  recognized  a  form  of  melancholia 
in  which  the  patients  are  so  completely  involved  in 
their  painful  feelings  that  they  lose  all  physical  activ- 
ity and  expression,  while  mentally  they  suffer  the  most 
acute  depression — the  so-called  melancholia  with 
stupor,  or  melancholia  attonita.  In  this  the  outward 
aspect  of  the  patient  is  in  extreme  cases  the  same  as 
that  in  stuporous  confusional  insanity,  except  that 
there  may  be  more  general  untidiness  and  refusal  of 
food.  The  exact  psychic  state  in  these  cases  is  uncer- 
tain ;  it  is  assumed  that  there  is  intense  depression,  that 
the  stupor  is  only  apparent,  and  that  the  impassive 
expression,  sometimes  with  an  anxious  or  terrified 
tinge,  is  only  a  mask  for  the  most  distressing  delusions 
or  hallucinations.  It  is  also  accounted  for  by  a  feeling 
of  restraint  or  inhibition  that  makes  movement,  and 
even  thought,  a  painful  effort.  Undoubtedly  this  last 
is  the  true  state  of  affairs  to  a  certain  extent,  but  in  the 
fully  developed  phase  it  may  be  a  question  whether 
this  fact  does  not  inhibit  also  the  painful  feelings  and 
the  patient's  full  appreciation  of  his  misery.  In  a 
much  larger  proportion  of  cases  we  have  a  partial  in- 
hibition, the  patient  shows  some  realization  of  his 
surroundings,  and  his  manner  and  expression  are  not 
passively  stuporous  or  impassive;  there  is  evident  an 
actual  distressful  state  of  mind,  but  we  have  not  always 
been  able  to  satisfy  ourselves  that  the  real  melancholic 
element  was  as  intense  in  this  phase  as  it  is  in  the 
more  active  forms  of  the  disorder.  These  patients  are 
liable  to  sudden  outbreaks  of  violence  or  suicidal  im- 
pulses, but  close  questioning  after  convalescence  does 
not  show,  as  a  rule,  that  the  attempts  were  directly 
due  to  intense  mental  depression.  One  very  typical 
case  of  this  kind,  who  made  a  desperately  persistent 
attempt  at  suicide,  told  later,  after  recovery,  that 
while  he  remembered  the  facts,  and  thought  he  also 
could  recall  his  feelings  at  the  time,  his  suicidal  at- 
13 


194  MELANCHOLIA. 

tempt  was  altogether  the  result  of  a  delusional  idea 
— he  thought  he  had  to  do  it. 

We  are  inclined  to  think  that  the  more  nearly  the 
outward  manifestations  approach  to  those  of  stupor, 
the  closer  related  also  are  the  psychic  conditions;  the 
mental  inhibition  involves  the  painful  feelings  as  well 
as  the  other  mental  activities.  The  really  greatest 
sufferers  are  those  who  preserve  to  the  fullest  extent 
their  normal  capacities;  and  that  the  inhibition  of 
these  benumbs  also  the  sensibility  to  psychic  pain  is 
true,  at  least  in  many  or  most  cases.  These  stuporous 
and  semi-stuporous  forms  of  melancholia  also  graduate 
into  certain  of  the  chronic  types  in  which  dementia  is 
the  most  prominent  psychic  feature,  though  with  a 
very  pronounced  depressive  tinge.  For  this  reason 
also  we  are  inclined  to  doubt  the  existence  of  the 
excessive  mental  anguish  and  terrifying  delusions  and 
hallucinations  that  are  said  to  be  so  characteristic. 

Some  of  the  physical  signs  or  symptoms  of  melan- 
cholia have  been  previously  noticed.  The  sleep  is  very 
generally  disturbed ;  insomnia  to  a  greater  or  less  degree 
is  the  rule.  When  the  patients  do  sleep,  their  rest  is 
disturbed  by  fearful  dreams,  and  is  broken  up  by 
intervals  of  distressed  wakefulness.  Some  patients 
sleep  fairly  well,  but  it  is  often  noticeable  that  on 
waking  the  mental  depression  is  more  evident  and 
severe  than  after  they  have  been  long  awake.  Indeed, 
it  is  a  very  common  observation  that  melancholiacs 
brighten  up  at  the  close  of  the  day,  to  relapse  again 
after  their  night's  rest. 

The  bowels  are  habitually  constipated,  at  least  in 
the  beginning,  and  this  is  apt  to  be  the  tendency 
throughout.  Attention  to  this  matter  is,  as  in  con- 
fusional  insanity,  one  of  the  most  important  points  in 
the  treatment. 

The  skin  is  often  pale  or  sallow,  its  surface  dry,  and 
in  old  cases  there  is  sometimes  a  sort  of  semi-asphyxi- 


SYMPTOMS.  195 

ated  condition  of  the  lower  limbs,  especially  when  the 
skin  becomes  cracked,  producing  occasionally  a  sort  of 
ichthyosis.     The  circulation  is  generally  poor,   or  at 
least  disordered,  and  this  is  particularly  the  case  in  the 
old    semi-stuporous   cases.     The   pulse   is    small   and 
irregular,  and  the  temperature  may  be  subnormal.     In 
the  agitated  cases   a   special   symptom  is  sometimes 
prominent;   they   complain   of   an   oppression   in   the 
chest,  a  precordial  pain,  which  is  probably  due  to  a 
special  neurosis  of  the  pneumogastric ;  it  is  not  by  any 
means  universally  observed,  even  in  these  cases,  but 
it  is  not  infrequent,  though  more  has  been  made  of  it 
than  its  real  importance  justifies.     The  patients  often 
complain  also  of  pain  in  the  head,  which  is  probably 
still  more  common,  though  not  always  revealed.     The 
subjective  sensations  of  melancholiacs  are  not  all  easy 
to  detect  in  extreme  cases ;  a  few  prominent  ones  may 
mask  many  that  are  more  obscure.     There  is  doubtless 
a  certain  degree  of  anesthesia  or  analgesia  to  many 
uncomfortable  sensations  that  would  be  unbearable 
to  one  not  so  engrossed  in  his  general  misery.     This 
accounts  in  part  for  the  persistence  of  the  refusal  of 
food  as  already  indicated,  and  it  may  also  be  possibly 
invoked  to  explain  the  indifference  to  self-injury  or 
mutilation    sometimes    observed.     An    acute    melan- 
choliac  has  been  known  to  thrust  his  head  into  a  heated 
stove,  and  later  to  resist  every  attempt  at  dressing  the 
burns  or  the  administration  of  anodynes  to  relieve  the 
pain  he  must  have  felt,  and  some  of  the  persistent  at- 
tempts at  self-mutilation  can  hardly  be  explainable 
except  on  the  theory  that  pain  was  not  normally  felt. 
The  refusal  of  food  is  an  almost  universal  symptom 
of  melancholia  in  its  acute  stages,  though  it  is  not 
always  a  constant  or  permanent  one.     The  motive  or 
cause  is  partly  psychic  and  partly  physical;  the  pa- 
tients refuse  food,  partially  on  account  of  their  delu- 
sions— they  are  unworthy,  it  does  not  belong  to  them, 


196  MELANCHOLIA. 

sometimes  it  is  because  they  deliberately  wish  to 
starve  themselves.  On  the  other  hand,  there  is  very 
commonly  a  lack  of  appetite,  due  to  the  gastric  de- 
rangement, or,  it  may  be,  to  a  direct  anesthesia  of  the 
hunger  sense.  The  patients  often  actively  resist  feed- 
ing in  the  agitated  forms  of  the  disease,  but  in  the 
quieter  stages  their  resistance  is  usualry  more  passive 
and  easily  overcome,  and  sometimes  it  is  only  neces- 
sary to  feed  them  occasionally,  and  some  melancholiacs 
even  in  their  frenzied  condition  eat  fairly  well  much 
of  the  time.  In  a  few  instances,  however,  continuous 
artificial  feeding  is  required  for  weeks  or  months  at  a 
time. 

The  suicidal  tendency  is  very  general  in  melancholia, 
and  the  greatest  vigilance  is  required  to  guard  against 
successful  attempts;  the  greatest  danger  is  in  those 
cases  that  are  quiet  and  liable  to  put  the  physician  and 
attendants  off  their  guard.  The  ingenuity  and  per- 
severance of  some  of  these  patients  are  remarkable, 
and  the  means  and  methods  sometimes  employed  are 
such  as  only  the  utmost  watchfulness  and  care  could 
forestall,  and  no  one  could  very  well  anticipate.  Some 
patients  are  capable  of  sufficient  self-control  to  simulate 
improvement  for  the  purpose  of  putting  their  attend- 
ants off  their  guard ;  others  are  liable  to  sudden  impulses 
in  this  direction  when  apparently  least  depressed. 
There  is  no  form  or  condition  of  melancholia  that  can 
be  said  to  be  free  from  this  peril;  all  melancholiacs, 
even  the  mildest  cases,  are  to  be  considered  dangerous 
in  this  regard. 

Homicide  has  been  already  referred  to  as  a  possible 
danger  in  this  form  of  insanity.  It  may  be  due  to  the 
patient's  delusions;  he  may,  with  his  self-accusatory 
ideas,  also  believe  that  he  is  causing  the  misery  of 
others  by  allowing  them  to  exist,  or  that  by  killing  them 
he  is  saving  others  from  a  fate  similar  or  worse  than  his 
own.     The  apparent  severity  or  intensity  of  depression 


PATHOLOGIC    ANATOMY.  197 

is  no  safe  guide  as  to  either  suicidal  or  homicidal  ten- 
dencies, for  these  may  exist  in  the  mild  reasoning  mel- 
ancholia as  well  as  in  agitated  frenzy.  In  the  latter 
conditions  either  homicide  or  suicide  is  likely  to  be 
more  impulsive,  and  not  so  directly  associated  with 
delusive  conceptions ;  the  attempt  may  be  inspired  by 
a  sudden  fear  or  an  exacerbation  of  the  anguish,  physi- 
cal or  mental,  for  the  moment. 

Pathologic  Anatomy. — The  pathologic  changes  in 
the  brain  in  melancholia  have  not  been  satisfactorily 
demonstrated,  at  least  so  far  as  regards  any  character- 
istic lesions.  The  brain  when  examined  in  the  acute 
stages  of  the  disorder  shows  little  in  the  way  of  gross 
changes,  and  the  microscopic  alterations  have  not 
been  well  determined.  The  fact  that  it  is  a  common 
disorder  in  the  early  stages  of  physical  decadence  is 
suggestive,  and  its  frequent  association  with  and 
aggravation  by  autotoxic  conditions  is  also  an  im- 
portant indication  as  to  the  changes  that  may  take 
place.  It  may  be  said  that  it  is  especially  a  disorder 
of  cerebral  nutrition ;  of  failure  or  defect  of  the  normal 
metabolism,  either  in  the  way  of  anemia  or  congestion 
at  times ;  or  of  defective  elimination  of  products  that 
give  rise  to  ischemic  conditions  and  molecular  dis- 
turbances in  the  cerebral  gray  matter.  The  exact 
mechanism  is  unknown.  In  chronic  melancholia  we 
have  the  changes  met  with  in  other  terminal  conditions 
of  insanity — brain  waste,  vascular  degeneration,  men- 
ingeal thickenings  and  opacities,  and  the  other  cere- 
bral concomitants  of  terminal  dementia. 

J.  Turner  *  and  Adolf  Meyer  f  have  described  cer- 
tain cell  alterations  in  cases  of  depressive  alienation, — 
shrinking  of  the  cell,  achromophilia,  dislocation  of  nu- 
cleus, etc., — which  the  first-named  author  considers  to 
be  the  characteristic  lesions  of  melancholia.     He  holds 

*"Brit.  Med.  Jour.,"  Oct.  26,  1901. 
f  "  Brain,"  spring  number,  1901. 


198  MELANCHOLIA. 

melancholia  to  be  due  to  an  interruption  or  embarrass- 
ment of  afferent  impulses,  and  that  the  similarity  of 
the  conditions  to  those  due  to  severance  of  the  axis 
cylinders  or  to  those  on  Clarke's  columns  after  division 
of  the  posterior  spinal  columns  (Warrington)  bears  out 
this  view.  He  also  considers  the  prognosis  of  melan- 
cholia graver  than  it  has  usually  been  considered. 
Meyer  has,  however,  observed  similar  cell  changes  in 
other  conditions,  and  it  seems  doubtful  whether  they 
are  as  characteristic  as  Turner  believes.  His  views, 
moreover,  do  not,  it  seems  to  us,  take  into  account  the 
milder  or  temporary  cases  of  melancholia  where  such 
advanced  pathologic  conditions  are  improbable,  and 
these,  as  has  been  said  before,  are  probably  by  far  the 
most  numerous  and  the  most  curable. 

Course  and  Termination. — Melancholia  is  a  disease 
generally  of  slow  progress  and  long  duration.  There 
are  undoubtedly  many  cases  of  the  milder  type  that 
may  last  only  a  short  time,  but  these  seldom  come 
under  the  observation  of  the  alienist,  and  it  may  be 
accepted  as  the  rule  that  any  well-defined  cases  of  pure 
melancholia  have  a  gradual  onset  and  recovery,  and  a 
total  duration  lasting  many  weeks  or  months.  It  is 
usually  a  considerable  time  after  the  first  symptoms 
have  appeared  before  the  disease  is  fully  recognized  by 
the  patient's  friends ;  the  cases  of  rapid  onset  are  excep- 
tional. The  stage  of  full  development  usually  lasts  for 
some  weeks  or  months  before  convalescence  begins, 
and  there  may  be  apparent  remissions  or  oscillations 
of  the  disorder.  Some  patients  appear  to  be  on  the 
road  to  recovery  several  times  before  actual  permanent 
improvement  sets  in. 

A  genuine  return  to  the  normal  condition  is  generally 
attended  with  physical  as  well  as  mental  improvement, 
and  the  recurrence  of  both  these  together  is  one  of  the 
most  hopeful  features  of  the  case.  The  patient  regains 
normal   sleep   and   appetite,    the   delusions   gradually 


COURSE    AND    TERMINATION.  IQ9 

become  less  prominent,  and  finally  disappear;  the 
mental  depression  also  becomes  less  prominent,  and 
the  patient  begins  to  take  interest  in  his  surroundings 
and  occupations,  till  at  last  there  is  little  left  of  the 
morbid  condition,  and  the  disease  is  practically  eradi- 
cated. In  some  cases  an  accident,  as  a  complicating 
affection,  will  apparently  have  a  favorable  influence, 
and  be  the  starting-point  of  a  recovery.  We  have 
repeatedly  seen  remissions  attend  a  severe  inflamma- 
tory affection,  and  even  a  simple  furuncle  of  the  face 
or  neck  has  been  accompanied  with  very  marked 
mental  improvement  for  the  time.  A  woman  who, 
in  the  condition  of  extreme  depression,  made  an 
attempt  at  suicide  by  setting  fire  to  her  clothing,  using 
for  the  purpose  a  letter  she  had  hidden  away  and  light- 
ing it  from  the  gas-jet,  dated  her  own  recovery,  and 
apparently  with  good  reason,  from  that  attempt.  The 
severe  burns  which  she  received  seemed  to  completely 
divert  her  mental  processes.  Other  cases  of  similar 
nature  could  be  reported;  they  are  not  so  rare  as  not 
to  be  within  the  observation  of  most  practical  phy- 
sicians who  have  to  do  with  the  insane. 

When  recovery  does  not  take  place,  there  are  several 
possible  terminations  of  an  attack  of  melancholia. 
The  danger  of  suicide  has  been  mentioned,  but  death 
may  result  from  the  disease  in  other  ways.  The  wear 
and  strain  upon  the  system  in  agitated  melancholia 
may  directly  overcome  the  patient's  vital  resistance, 
and  death  may  ensue  from  what  is  commonly  called  in 
asylum  statistics  the  exhaustion  of  acute  melancholia. 

The  defective  nutrition  and  the  probable  action  of 
toxins  produced  in  the  system,  together  with  the  over- 
taxation of  the  nerve-centers  through  the  constant 
restlessness  and  failure  of  repair  in  sleep,  can  account 
for  many  of  these  deaths,  without  invoking  any  inter- 
current disorder.  It  is  a  fact,  however,  that  lesions 
of   important   viscera   are   very   commonly   found   in 


200  MELANCHOLIA. 

autopsies  of  these  cases,  the  lungs  are  often  diseased, 
and  degenerative  changes  in  the  liver  are  especially 
frequent.  These  latter  may  possibly  be  accounted  for 
by  the  overtaxation  of  the  defensive  function  of  the 
organ  by  auto-toxins,  which  must  be  abundantly 
produced  in  the  disordered  organism. 

Death  may  also  occur  from  so-called  exhaustion  or 
marasmus  in  other  forms  of  melancholia,  the  stuporous 
or  semi-stuporous  type  more  particularly,  probably  in 
part  by  the  same  mechanism  of  auto-intoxication  as 
in  the  agitated  form.  In  these  cases  the  ordinary 
vital  resistance  of  the  system  is  also  so  lowered  that 
the}^  readily  become  the  victims  of  lung  disorders,  and 
these  are  to  be  credited  with  many  of  the  fatalities  of 
this  disease.  The  patients  do  not  always  reveal  their 
condition  by  the  S3^mptoms,  and  it  is  probable  that 
many  cases  not  so  credited  ought  to  be  attributed  to 
lung  and  other  complications. 

"When  neither  death  nor  recovery  ends  the  scene,  the 
patient  passes  into  what  is  called  the  chronic  form  of 
the  disease,  generally  a  milder  and  more  continuous 
condition  of  mental  depression,  tinged  with  delusional 
ideas,  and  not  uncommonly  associated  with  a  greater 
or  less  degree  of  general  mental  impairment.  In  fact, 
while  it  is  commonly  said  that  dementia  does  not 
usually  exist,  it  is  hard  to  say  that  a  case  of  melan- 
cholia has  really  passed  into  the  chronic  stage  without 
there  exists  a  certain  degree  of  mental  impairment. 
There  is  no  fixed  time  limit  for  curable  or  acute  melan- 
cholia, and  where  pronounced  dementia  has  not  ap- 
peared, it  is  impossible  to  say  that  the  case  is  beyond 
the  chance  of  recovery,  or  at  least  of  recovery  with 
some  possible  permanent  defect.  The  patients  may 
be  noticeably  peculiar,  and  may  have  perverted  notions 
or  ideas  in  regard  to  their  friends,  or  on  certain  special 
subjects,  but  they  are  in  other  respects  rational  and 
capable  of  resuming  their  former  avocations,  and  to  a 


COURSE    AND    TERMINATION.  201 

large  extent  their  former  position  in  society.  When 
the  disorder  has,  however,  passed  into  the  chronic 
stage,  it  may  take  peculiar  forms,  one  or  two  of  which 
have  been  so  often  observed  as  to  have  received  special 
names,  and  have  been  proposed  as  clinical  varieties. 
One  of  them  is  the  so-called  insanity  of  negation 
(delire  des  negations,  of  Cotard),  in  which  the  patient 
denies  everything — his  own  existence,  the  reality  of 
things  about  him,  etc.  Still  another  type  is  that  of  a 
sort  of  secondary  paranoia,  in  which  the  delusional 
ideas  are  most  prominent,  and  while  sometimes  of  a 
megalomaniac  character,  are  yet  generally  tinctured 
more  or  less  with  the  general  depressive  character 
of  the  original  disorder.  While  recovery  is  not  prob- 
able in  these  chronic  forms,  it  sometimes  occurs  in 
these  paranoiac  types  at  least.  In  one  case  that  came 
under  the  observation  of  the  writers,  a  woman  whose 
insanity  dated  from  the  seduction  of  her  daughter,  and 
began  as  typical  melancholia,  took  on  the  paranoiac 
type  after  a  few  years,  the  delusions  being  of  a  rather 
fantastic  type,  though  somewhat  systematized.  One  of 
them  was  that  she  was  compelled  to  swallow  the  whole 
world,  which  distressed  her  the  more,  the  more  it  was 
ridiculed  by  others  about  her.  She  was  amiable  in 
disposition  and  inclined  to  be  industrious,  and  as 
suicidal  tendencies  appeared  to  be  lacking,  she  was 
allowed  to  return  to  her  relatives  on  furlough.  This 
was  repeated  more  than  once,  and  finally  she  received 
her  discharge  as  safe  to  be  at  large.  She  was,  however, 
kept  more  or  less  under  observation,  as  her  home  was 
near  the  asylum,  and  she  finally  made  a  good  recovery 
after  a  total  of  ten  or  twelve  years  of  insanity.  A 
noticeable  feature  in  her  case  was  that  while  previous  to 
her  recovery,  which  occurred  with  the  change  of  life,  she 
had  become  quite  fleshy,  with  it  she  became  quite  thin, 
though  muscular  and  wiry,  and  otherwise  in  good 
physical  condition. 


202  MELANCHOLIA. 

Prognosis. — From  what  has  been  already  said,  it 
is  seen  that  melancholia  is  one  of  the  specially 
curable  forms  of  mental  disorder.  If  all  the  mildest 
types  are  included, — the  walking  cases  that  do  not 
come  under  the  asylum  physician's  care  and  are  only 
the  office  patients  of  the  family  physician  or  the 
neurologic  specialist, — it  is  probably  the  most  curable 
of  all  the  forms  of  insanity.  While  they  last,  these 
cases  are  dangerous,  especially  as  regards  suicide;  but 
a  very  large  proportion  of  them,  it  is  believed,  recover 
without  ever  being  generally  recognized  as  insane.  It 
is  commonly  estimated  that  about  50%  also  of  the 
asylum  cases  of  pronounced  melancholia  recover  either 
completely  or  with  very  slight  defect.  Kraepelin,  who 
recognizes  it  only  as  a  senile  affection,  estimates  his 
complete  recoveries  at  32%,  and  the  more  or  less 
incomplete  ones  at  23%.  He  observed,  however,  that 
the  prognosis  was  much  better  in  cases  under  fifty-five 
years  of  age  than  in  those  beyond  that  age. 

Some  allowance  must  probably  be  made  in  the 
statistics  for  the  possible  inclusion  of  cases  of  the 
depressed  forms  of  acute  confusional  insanity,  which 
would  unduly  raise  the  percentage.  The  confounding 
of  cases  of  periodic  depressed  insanity  with  true  melan- 
cholia is  also  another  possibility  to  be  considered. 
Allowing,  however,  for  both  of  these,  we  may  still 
estimate  with  approximate  correctness  that  a  large 
proportion  of  cases  of  melancholia  recover,  even  not 
including  the  milder  and  often  unrecognized  attacks. 
It  has  been  already  stated  that  there  is  no  time  limit 
to  acute  curable  melancholia;  more  than  any  other 
form  of  mental  disease  it  shows  cures  after  a  long  dura- 
tion of  the  symptoms,  and  the  tendency  to  terminal 
dementia  is  less  marked  than  is  usually  the  case  with 
the  lapse  of  time  and  continuance  of  the  mental 
derangement. 

It  is  claimed  that  statistics  show  a  seasonal  variation 


TREATMENT.  203 

in  the  recoveries  from  melancholia;  that  more  recov- 
eries occur  in  the  springtime  than  at  other  seasons  of 
the  year.  So  far  as  this  is  true,  it  is  probably  due  to 
the  more  cheerful  and  brighter  climatic  conditions  exist- 
ing at  this  period,  and  the  greater  amount  of  open  air 
and  exercise  allowable  at  this  season,  when  also  the 
oppressive  heat  of  summer  has  not  yet  had  any  dele- 
terious influence. 

Treatment. — The  treatment  of  melancholia  varies 
with  the  character  of  the  attack,  its  stages,  and  the 
opportunities  and  facilities  of  the  patient's  circum- 
stances. There  is  probably  no  form  of  insanity  that 
is  more  often  the  subject  of  home  treatment  than  this, 
especially  in  the  milder  or  slighter  forms.  A  large 
proportion  of  these  cases,  in  fact,  get  well  without  any 
treatment  whatever  except  such  as  the  patient  can 
give  himself.  Some,  feeling  the  need  of  change  of 
scene,  travel,  and  the  effect  is  good;  others  deliberately 
work  off  their  depression  in  their  ordinary  daily  occu- 
pations, or  with  such  diversions  as  they  can  devise  for 
themselves.  When,  however,  the  disorder  has  become 
well  established,  the  patient  is  comparatively  helpless, 
and  generally  outside  aid  is  required.  An  excellent 
thing  for  many  of  these  cases  would  be  a  sojourn  in  a 
sanitarium  or  similar  institution,  where,  without  the 
name  of  being  inmates  of  an  asylum,  they  could  have 
the  regulated  living,  the  oversight  and  attendance,  and 
the  medical  treatment  they  require.  Unfortunately, 
the  expense  of  such  a  change  of  scene  and  surroundings 
is  to  many  an  insuperable  bar  to  the  treatment,  and, 
if  it  cannot  be  met,  isolation  and  removal  from  the 
ordinary  conditions  of  living  are  advisable,  and  this 
can  best  be  managed  at  home  by  the  "rest  in  bed" 
treatment.  It  may  be  difficult  to  enforce  this  in  the 
milder  cases;  but  when  the  patient's  melancholia  is 
well  developed,  there  will  be  good  reason  for  it  as  a  sort 
of  needful  restraint ;  and  if  the  patient  is  sent  to  a 


204  MELANCHOLIA. 

hospital  for  the  insane,  it  will  be  in  many  cases  the  best 
treatment  to  be  adopted  there.  At  the  patient's  home 
it  has  the  drawback  of  requiring  close  day  and  night 
attendance  by  those  who  can  be  fully  trusted  to  be 
watchful  and  carry  out  orders,  and  these  cannot  always 
be  obtained.  Trained  asylum  attendants  are  better 
for  these  cases  than  ordinary  trained  nurses,  in  view 
of  the  constant  watchfulness  required;  the  latter  do 
not  always  fully  appreciate  the  necessity  of  this,  and 
accidents  may  occur. 

The  first  things  to  attend  to  in  the  care  of  melan- 
choliacs  are  that  they  obtain  proper  nourishment  and 
sleep,  and  have  the  constipated  condition  relieved,  and 
the  routine  method  of  the  rest  in  bed  treatment  attends 
to  all  these  matters.  The  patient  receives  a  thorough 
enema,  is  given  a  warm  bath,  and  food  is  administered; 
the  prone  position  and  the  above  antecedents  favor  the 
giving  of  food,  and  it  is  sometimes  possible  to  make 
the  patients  eat  or  accept  their  food  as  given  them 
without  resistance.  In  extreme  cases,  however,  arti- 
ficial feeding  is  generally  required,  and  it  can  be  done 
to  the  best  advantage  under  these  conditions.  As  the 
stomach  is  often  or  even  generally  disordered  to  some 
extent,  it  will  be  well  to  investigate  its  condition,  if 
possible,  and  in  many  cases  warm  water  lavage,  with 
perhaps  some  safe  disinfectant  added,  may  be  advis- 
able. As  these  patients  generally  refuse  medicine  as 
well  as  food,  both  can  be  given  together  by  the  feeding- 
tube  when  necessary.  Food  should  be  given  at  least 
twice  a  day,  and  oftener  if  not  contraindicated,  if  the 
feeding-tube  has  to  be  used,  and  should  consist  largely 
of  milk  and  eggs.  The  bowels  should  be  carefully 
attended  to,  and  with  the  laxatives  and  enemata  some 
intestinal  antiseptic  is  often  useful.  Insomnia  is  com- 
bated by  warm  baths;  in  some  cases  also  by  mild 
alcoholic  stimulation  and  opium,  or  other  hypnotics. 

The  only  specific  drug  treatment  of  melancholia  that 


TREATMENT.  205 

has  much  testimony  in  its  favor  is  that  with  opium 
in  gradually  increasing  doses,  as  the  patient  gains  a 
toleration  of  the  drug.  As  much  as  forty  or  fifty 
minims  of  laudanum  or  other  liquid  preparation  of  like 
strength,  three  times  a  day,  have  been  reached  in  this 
way  as  the  regular  dose.  This,  in  cases  suited  for  it, 
does  not  appear  to  increase  constipation,  but  to  have 
rather  the  contrary  effect,  and  there  is  not  usually  a 
danger  of  producing  a  habit,  or  difficulty  in  stopping 
the  drug  when  required.  It  is  not  by  any  means  a 
specific,  however,  and  in  some  cases  it  has  a  directly 
opposite  effect  from  that  desired.  The  administration 
of  any  drug  in  melancholia  should  be  kept  closely  under 
the  charge  of  the  physician,  and  carefully  watched  as 
to  its  effects.  As  the  case  progresses  toward  recovery, 
tonics — quinin,  iron,  and  strychnin — are  often  advis- 
able. 


CHAPTER  XII. 
THE  TOXIC  INSANITIES, 

The  toxic  insanities  are  included  here  in  the  general 
group  of  the  acquired  mental  disorders,  though,  like 
the  other  members  of  that  group,  they  may  be,  and 
often  are,  complicated  more  or  less  with  heredity  and 
degenerative  taint.  The  fact,  however,  that  they 
may  occur  de  novo  in  normal  individuals  is  a  sufficient 
reason  for  their  position  in  the  classification.  It  is 
said,  indeed,  by  some  that  alcoholic  insanity  is  a  degen- 
erative type,  that  only  degenerates  become  inebriates ; 
but  this  opinion  has  not  the  support  of  the  general 
experience  and  common  sense  of  mankind.  It  is  a 
common  cause  and  origin  of  degeneracy,  it  is  true,  but 
it  is  not  necessarily  an  indication  of  prior  mental  weak- 
ness any  more  than  is  insanity  from  lead  or  carbonic 
acid  poisoning,  or  traumatic  insanity.  An  inherited 
taint  may  be  a  factor  in  causing  a  man  to  become  a 
drunkard,  but  he  can  also  become  one  without  it.  The 
same  is  still  more  true  of  morphinic  mental  derange- 
ment, and  of  the  toxin  insanities,  like  paresis. 

The  toxic  insanities  fall  readily  into  two  clinical 
groups:  the  drug  insanities  and  intoxications,  and  the 
toxin  forms.  The  first  of  these  is  more  distinct  in  its 
generally  obvious  causation ;  the  second  is  less  clear  in 
its  origin,  and  has  not  been  so  universally  recognized 
as  pertaining  to  this  general  class.  The  whole  group 
is  very  illustrative  of  the  difficulties  of  making  a  per- 
fect etiologic  classification  of  mental  diseases,  though 
clinically  quite  well  marked  and  distinct. 

The  drug  insanities  are   of  special  interest  to  the 

206 


ALCOHOLIC    INSANITY.  207 

alienist,  since  here  we  have  a  direct  visible  connection 
between  cause  and  effect,  and  one  that  cannot  be  as 
easily  established  in  any  other  of  the  morbid  psychoses, 
except,  it  may  be,  in  the  insanities  of  organic  brain 
disease.  While  we  may  admit  that  in  many  cases  there 
was  a  defective  original  organization,  a  weakness  that 
succumbed  in  time'  of  trial  and  under  circumstances 
in  which  a  normal  individual  would  have  resisted,  yet 
we  can  see  and  know  that  the  insanity  was  the  direct 
and  immediate  result  of  the  intoxication.  These  in- 
sanities, moreover,  have  their  distinct  clinical  char- 
acteristics that  appear  only  with  these  agents  acting 
as  the  cause. 

ALCOHOLIC  INSANITY. 

The  effects  of  alcohol  on  the  brain  and  central  ner- 
vous system  generally  are  matters  of  too  common 
observation.  We  all  know  the  symptoms  of  ordinary 
intoxication,  but  we  are  not  always  awake  to  the  fact 
that  even  small  amounts,  well  within  the  limits  of  that 
which  it  is  claimed  can  be  economically  consumed  in 
the  body,  have  a  decided,  though  not  directly  apparent, 
deleterious  effect  upon  the  function  of  the  nervous 
system.  Aschaffenberg's  experiments  upon  the  work- 
ing capacity  of  type-setters  with  and  without  the  in- 
gestion of  small  amounts  of  alcohol  demonstrate  this 
fact.  The  action  of  alcohol  being  thus  primarily  on 
the  nerve  elements,  it  is  the  more  easy  to  perceive  the 
injurious  effects  of  its  long-continued  or  excessive  use. 
Any  marked  cerebral  intoxication  produced  by  alco- 
holic excess  is  really  a  temporary  insanity,  but  its 
brief  duration  puts  it  out  of  the  category  here  con- 
sidered. It  is  only  when  the  alcoholic  indulgence, 
either  by  its  excess  or  individual  idiosyncrasy,  produces 
still  more  marked  symptoms  of  mental  aberration  that 
we  speak  of  acute  alcoholic  insanity,  and  only  when 
its  prolonged  usage  has  given  rise  to  permanent  changes 


208  THE    TOXIC    INSANITIES. 

in  character  and  intellection  that  we  call  it  chronic 
alcoholism. 

The  most  familiar  form  of  acute  alcoholic  derange- 
ment is  the  well-known  delirium  tremens,  a  condition 
that  follows  a  protracted  and  excessive  indulgence  in 
liquor.  It  is  more  than  a  simple  intoxication;  it  is  a 
general  systemic  disturbance  as  well  as  a  mental  dis- 
order, and  a  serious  one,  not  infrequently  terminating 
fatally.  Two  of  its  characteristic  symptoms  are  in- 
dicated in  its  designation — delirium  and  tremor.  The 
patient,  generally  after  a  protracted  drinking  spell, 
finds  himself  restless,  sleepless,  and  tremulous,  with  a 
tendency  to  excessive  irritability.  This  stage  may  not 
be  passed  if  alcohol  is  discontinued  and  proper  remedies 
employed,  but  it  usually  passes  rapidly  into  the  second 
stage,  that  of  delirium.  Up  to  this  time  consciousness 
and  reason  may  be  retained  to  a  large  degree ;  the  in- 
dividual may,  indeed,  not  have  presented  even  the 
ordinary  symptoms  of  intoxication.  The  delirium  is 
ushered  in  by  the  appearance  of  illusions  and  hallucina- 
tions, largely  visual,  though  auditory,  gustatory,  tac- 
tile, and  other  sensory  hallucinations  are  not  at  all  infre- 
quent. The  commonest  character  is  their  disagreeable 
and  alarming  nature ;  the  patient  sees  snakes,  spiders, 
has  ants  crawling  over  him,  feels  as  though  his  mouth 
is  full  of  wires,  smells  bad  odors,  etc.  Delusions  and 
illusions  of  identity  are  common,  and  the  intellectual 
involvement  is  shown  in  the  inability  to  control  atten- 
tion and  to  rightly  interpret  external  impressions. 
Many  of  the  hallucinations  are  really  illusions;  actual 
perceptions  are  misinterpreted,  and  others  are  directly 
the  consequence  of  external  irritation  of  the  perceptive 
organs.  The  unpleasant  character  of  these  impressions 
reacts  upon  the  emotions,  and  the  general  mental  con- 
dition of  these  subjects  is  one  of  fright  or  worry;  this, 
with  the  motor  restlessness,  giving  rise  to  extraordinary 
actions,  and  often  to  suicidal  or  homicidal  attempts. 


ALCOHOLIC    INSANITY.  209 

Conscious  memory  of  acts  may  be  lost,  and  the  patient 
has  later  little  or  no  recollection  of  what  has  passed. 

The  physical  condition  during  this  stage  is  profoundly 
affected;  the  appetite  is  lost,  the  secretions  deranged, 
there  may  be  even  convulsions.  The  tremor  is  fine 
and  constant,  but  generally  observable.  The  usual 
termination  is  in  recovery,  but  in  some  cases  there  is 
marked  febrile  movement,  the  temperature  rising  to 
10 50  or  even  more,  and  in  such  cases  death  is  liable  to 
be  the  outcome.  In  ordinary  cases  there  is  little  or  no 
fever  unless  some  complication,  such  as  pneumonia  or 
the  severe  meningitis  above  referred  to,  occurs.  The 
treatment  is  simple ;  sleep  must  be  secured,  and  this  is 
in  most  cases  best  accomplished  by  the  use  of  opium 
or  morphin,  sometimes  combined  with  other  hypnotics, 
such  as  chloral ;  the  patient's  strength  must  be  kept  up 
by  judicious  feeding,  which  may  at  times  be  attended 
with  some  difficulty,  as  the  patient's  stomach  is  liable 
to  reject  food,  and  his  mental  condition  is  often  such 
as  to  make  it  no  easy  task  to  induce  him  to  take  food. 
It  is  often  advised  to  use  small  doses  of  alcohol  as  a 
stimulant,  but  other  stimulants,  especially  strychnin, 
are  better  and  safer  in  every  way.  This  is  in  severe 
cases;  milder  ones  in  fairly  robust  subjects  will  often 
recover  with  no  treatment  other  than  the  withdrawal 
of  alcoholics.  If  the  case  can  be  taken  before  the  stage 
of  full  delirium,  a  mild  sedative  dose  of  bromid  is  often 
sufficient  to  put  the  patient  on  the  way  to  recovery. 
As  a  rule,  after  the  attack  the  state  of  health  will  require 
some  medical  care  for  at  least  a  few  days ;  more  or  less 
general  nervous  depression  and  derangement,  showing 
itself  in  tremor,  weakness,  disordered  cardiac  action,  etc. , 
will  be  present.  During  the  attack  itself  the  subject  will 
require  close  watching  to  prevent  violence,  and  especially 
self -injury  or  suicide.  Bed  treatment  (enforced)  is  ad- 
visable. 

While  the  stronger  alcoholic  drinks  are  most  likely 
14 


2IO  THE    TOXIC    INSANITIES. 

to  produce  delirium  tremens,  it  is  not  impossible  for  it 
to  occur  after  excessive  use  of  what  are  generally  con- 
sidered the  less  strong  alcoholic  beverages — wines, 
etc.  We  have  seen  a  well-marked  though  mild  attack 
follow  a  debauch  on  hard  cider  in  a  prohibition  farming 
community. 

In  degenerates  we  have  at  least  two  types  of  what 
may  be  called  acute  alcoholic  insanity,  quite  different 
from  delirium  tremens,  which  is  liable  to  occur  in  any 
one  who  indulges  in  prolonged  sprees  with  excessive 
ingestion  of  alcoholics.  These  are  acute  alcoholic 
mania  and  the  periodic  attacks  of  dipsomaniacs.  In 
certain  predisposed  individuals  any  pronounced  alco- 
holic excess  is  liable  to  produce  an  attack  of  typical 
mania  that  may  continue  for  only  a  short  time,  but  is 
attended  rather  more  frequently  than  the  ordinary 
acute  mania  with  a  very  decided  moral  deterioration. 
When  the  mania  in  these  cases  is  subacute  in  its  type, 
this  is  especially  liable  to  be  a  feature,  and  such  cases 
are  often  the  most  trying  patients  in  a  large  asylum 
while  they  are  inmates.  It  is  a  popular  notion  that 
denrium  tremens  is  a  common  result  of  stoppage  of 
habitual  steady  drinking,  but  there  is  little  ground  for 
such  belief,  and  if  such  cases  occur,  they  are  very  rare. 
We  have  seen,  however,  acute  mania  apparently  thus 
caused,  as  in  the  following  instance:  The  patient,  a 
man  of  about  forty,  had  been  a  hard  steady  drinker 
for  sixteen  years.  His  taking  the  pledge  was  followed 
immediately  by  an  acute  attack  of  mania,  for  which 
he  was  sent  to  the  asylum.  He  had  marked  degenera- 
tive stigmata,  the  most  notable  one  being  a  very  pro- 
nounced funnel-breast,  but  he  was  muscular  and  very 
active,  and  in  spite  of  his  habits  had  always  been  a 
capable  and  energetic  business  man.  His  insanity, 
which  was  a  first  attack,  was  of  the  ordinary  maniacal 
motor  type,  with,  however,  no  complete  impairment 
of  self-consciousness,  and  during  the  whole  attack  and 


CHRONIC    ALCOHOLIC    INSANITY.  211 

after  his  recovery,  which  was  rapid  and  apparently 
complete,  he  constantly  expressed  a  determination  to 
keep  his  pledge.  He  believed  during  his  attack  that 
it  was  caused  by  his  change  of  habits  and  was  a 
part  of  the  fight  he  had  to  make  against  them.  In 
this  case  the  suppression  of  the  alcohol  seemed  to  be 
the  exciting  cause  of  the  mania,  as  in  the  other  cases 
continued  excesses  had  the  same  effect.  They  are  per- 
haps not  properly  to  be  considered  as  cases  of  alcoholic 
insanity  except  etiologically,  as  the  disease  itself  is  not 
so  specially  characteristic,  and  it  occurs  in  already  pre- 
disposed individuals,  who  might  possibly  succumb  as 
readily  to  other  causes.  They  are  cases  of  degenera- 
tive mania  from  a  special  cause,  possibly  tinged  more 
or  less  in  their  symptoms  by  that  cause,  but  not  perhaps 
to  be  called  true  cases  of  alcoholic  insanity.  They  are 
mentioned  here  chiefly  because  they  are  likely  to  be  in- 
cluded in  the  alcoholic  insanities  on  account  of  their 
origin,  and  also  because  there  exists  a  little  more  than 
a  mere  causal  relation  between  them  and  the  true  toxic 
mental  derangement.  We  can  speak  with  some  reason 
of  an  alcoholic  mania  in  these  cases,  since  alcoholic  in- 
toxication is  its  direct  cause,  and  there  is  sufficient  that 
is  characteristic  about  it  to  associate  it  in  our  minds 
with  this  particular  origin,  knowing  its  existence.     , 

CHRONIC  ALCOHOLIC  INSANITY. 

The  continued  excessive  use  of  alcohol  has  its  effects 
on  the  mental  health  in  other  ways  than  in  producing 
acute  delirium  tremens  or  alcoholic  mania.  It  is  a 
matter  of  common  observation  that  the  steady  hard 
drinker  or  the  drunkard  deteriorates  morally;  that 
his  will-power  is  diminished;  that  he  becomes  a  slave 
to  his  appetites,  without  the  power  and  often  without 
the  desire  to  rise  out  of  the  rut  of  habit.  It  is  not  the 
same  in  all  cases,  but  in  some  this  deterioration  is  very 
evident ;  the  individual  becomes  unreliable,  untruthful, 


212  THE    TOXIC    INSANITIES. 

without  ambition  or  even  the  feeling  of  self-respect, 
and  neglectful  of  the  future  and  of  the  needs  of  himself 
and  family.  It  is  not  necessary  to  be  an  abject  sot  to 
be  thus  demoralized;  many  individuals  undergo  this 
complete  change  of  character  without  openly  appearing 
under  the  influence  of  liquor,  and  we  have  seen  this 
change  occur  from  a  habit  of  secret  drinking  alone, 
which  in  some  respects  and  in  some  persons  is  even 
more  dangerous  than  the  open  habit.  It  is  not  in 
accordance  with  custom  to  call  these  individuals  insane, 
but  they  have  made  themselves  mentally  abnormal, 
to  say  the  least.  The  tendency  and  almost  inevitable 
outcome  of  this  alcoholic  mental  and  moral  decay  is 
in  a  sort  of  moral  insanity,  showing  itself  in  vaga- 
bondage and  quasi-criminality,  and  the  victims  may  be 
regarded  as  only  partially  responsible,  in  some  respects, 
at  least. 

The  effects  of  the  steady  hard  drinking  are,  however, 
not  always  the  same.  Some  appear  to  escape  the  con- 
dition described  above ;  they  retain  their  judgment  and 
energy,  and  appear  like  good  citizens  and  capable 
business  men.  They  cannot  be  regarded  as  altogether 
escaping  the  effects  of  their  habit,  and  sometimes  a 
peculiarly  characteristic  form  of  alcoholic  insanity  may 
develop.  There  is  a  certain  degree  of  irritability  and 
suspiciousness  aroused  in  them,  especially  "when  in 
their  cups,"  and  while  they  may  be  able  to  control  this 
in  public,  in  their  families  it  is  manifest.  They  mis- 
interpret the  simplest  facts  and  build  up  complete 
delusions.  One  of  the  most  frequent  of  these  is  that  of 
conjugal  infidelity,  which  is  only  the  simple  result  of 
irritable  jealousy,  interpreting  the  natural  disgust  or 
precautions  for  self -protection  on  the  part  of  the  wife 
as  the  evidences  of  her  unfaithfulness,  and  this,  with 
the  ill-balanced  state  from  alcoholism,  develops  into  a 
fixed  delusion.  This  morbid  suspiciousness,  aggra- 
vated by  intellectual  weakness,  builds  up  sometimes 


CHRONIC    ALCOHOLIC    INSANITY.  213 

from  every  trivial  circumstance  new  evidence  in  sup- 
port of  the  delusion.  Chance  sounds  become  illusions 
of  hearing  pointing  in  the  same  way,  and  sometimes 
there  may  be  actual  hallucinations  excited  by  the 
morbid  attention  of  the  disordered  brain.  With  this 
there  may  be  complete  self-consciousness;  the  patient 
is  rational  in  other  respects.  These  delusions  may  con- 
tinue even  if  drinking  is  stopped,  and  it  is  not  always 
easy  to  be  sure  that  they  do  not  exist  at  times  as  a  sort 
of  imperative  conception  after  apparent  complete  re- 
covery. A  case  like  the  following  illustrates  this  very 
clearly:  A  hard-working  carpenter,  who  was  known  as  a 
regular  drinker,  though  seldom  or  never  openly  under 
the  influence  of  liquor,  had — possibly  aided  by  a  fall  in 
which  his  head  was  struck — a  delusion  of  this  kind 
develop  to  such  an  extent  that  he  was  considered  too 
dangerous  to  be  at  large,  and  was  committed  to  an 
asylum.  His  delusion  was  fixed  and  elaborately  de- 
tailed, though  extravagant;  he  believed  nearly  all  the 
male  residents  of  the  village  in  which  he  lived  were 
adulterers  with  his  wife.  In  every  other  respect  he 
appeared  rational,  and  after  a  short  detention  at  the 
asylum  these  delusions  became  less  prominent,  and  he 
was  placed  on  parole,  and  as  he  was  an  excellent  work- 
man, far  above  the  average,  he  was  soon  given  regular 
employment  on  wages.  His  delusions  apparently  dis- 
appeared, his  name  was  taken  off  the  books,  and  he 
became  a  regular  employee,  rented  a  house  nearby  and 
sent  for  his  family,  and  seemed  in  all  respects  again 
his  normal  self.  After  several  years'  faithful  service 
he  suddenly  attempted  suicide  by  shooting  himself  in 
the  head,  giving  as  a  reason  the  old  delusions.  The 
bullet  from  the  small  pistol  did  not  penetrate  the  skull, 
and  he  was  recommitted  to  another  asylum,  where  he 
died  shortly  after.  Another  case  similar  in  nearly 
every  respect  secured  his  release  from  the  asylum  and 
committed  suicide  within  a  month.     This  danger  of 


214  THE    TOXIC    INSANITIES. 

suicide  or  homicide  has  to  be  reckoned  with  in 
these  cases;  they  may  appear  perfectly  rational,  and 
yet  have  this  constantly  in  the  mind  or  planned  out, 
and  for  this  reason  they  are  cases  that  try  the  discretion 
of  physicians  and  asylum  superintendents  perhaps 
more  than  any  other  class .  A  rather  noted  sub  j  ect  of  this 
form  of  alcoholic  insanity  a  few  years  ago  called  on  a 
physician  and  shot  him  dead  at  his  door.  He  had 
been  an  asylum  inmate,  but  had  been  discharged  not 
long  before  because  the  mental  disorder  was  too  little 
apparent,  it  was  thought,  to  justify  his  detention,  and 
the  plea  of  insanity  in  his  case  was  disregarded  by  the 
jury,  who  sentenced  him  to  life  imprisonment.  His  was 
undoubtedly  a  case  of  chronic  delusional  alcoholic 
insanity. 

These  patients,  if  the  drinking  habits  are  kept  up, 
as  they  are  liable  to  be  intermittently,  are  occasionally 
subject  to  acute  or  subacute  delirious  or  maniacal  ex- 
acerbations ;  in  the  former  type  the  delusions  are  most 
apt  to  be  melancholic  or  terrifying,  but  they  occasion- 
ally take  on  an  exalted  or  megalomaniac  character; 
the  individual  has  unbounded  wealth,  projects  ex- 
travagant undertakings,  etc.  We  have  seen  a  case 
that  would  easily  be  taken,  both  from  the  character- 
istic grand  delirium,  the  tremor  and  thickened  speech, 
for  a  case  of  paretic  dementia,  but  for  the  known  facts 
of  its  etiology  and  the  rapid  and  complete  recovery 
under  treatment.  An  alcoholic  pseudo-paresis  has 
been  described  by  Regis  and  others  which  includes  such 
cases  as  the  above. 

In  old  cases  of  chronic  alcoholism,  with  the  mental 
deterioration  there  sometimes  is  seen  a  true  progressive 
paresis  with  special  characteristic  features.  The  fol- 
lowing case,  while  presenting  peculiar  features,  is 
typical  of  this  form  in  some  respects :  D.  R.  was  the  son 
of  well-to-do  but  intemperate  parents,  both  father  and 
mother  being  regular  hard  drinkers.     From  childhood 


CHRONIC    ALCOHOLIC    INSANITY.  215 

he  had  been  in  the  habit  of  using  alcohol  in  some  form, 
and  at  sixteen  or  eighteen  he  was  practically  a  con- 
firmed sot.  When  he  was  about  twenty-one  he  became 
so  troublesome,  his  mental  failure  was  so  apparent,  that 
he  was  committed  to  the  asylum  as  insane,  and  was  in  a 
condition  of  pronounced  dementia — could  give  no 
account  of  his  case,  was  unable  to  perform  the  simplest 
offices  for  himself,  untidy  and  somewhat  destructive 
in  his  habits.  Physically  he  was  well  nourished,  but 
decidedly  ataxic ;  his  speech  was  thick  like  that  of  a 
drunken  man,  and  there  was  a  peculiar  stiffness  as  well 
as  uncertainty  in  his  movements.  His  pupils  were 
equal,  and  normal  in  reaction,  but  there  was  a  marked 
intention  tremor  of  his  hands,  more  noticeable  at  some 
times  than  at  others.  His  general  appearance  was  not 
so  much  that  of  a  paretic  dement  as  of  a  drunken  man, 
and  his  mental  condition  also  suggested  this  condition. 
He  would  be  silly  and  elated,  and  then  change  in- 
stantly and  be  maudlin  and  weeping.  He  always 
wanted  whisky ;  and  if  asked  if  something  else,  wine  or 
beer,  would  not  do,  he  would  refuse — he  was  a  high- 
toned  gentleman,  and  nothing  but  whisky  or  brandy 
would  do  for  him;  all  other  drinks  were  "too  thin." 
In  spite  of  all  care  and  treatment,  his  paralysis  pro- 
gressively increased  and  his  general  condition,  mental 
and  physical,  deteriorated  till  dementia  became  almost 
absolute,  and  he  was  taken  out  by  friends  in  a  com- 
paratively helpless  state  to  die  at  home.  The  case  is 
typical  of  a  certain  proportion  of  alcoholic  paralysis, 
but  not  occurring  in  every  subject.  The  drunken 
manner  and  speech  of  this  patient  were  unique  in  our 
experience.  There  was  no  history  of  any  other  cause, 
and,  indeed,  no  suspicion  of  any,  except  alcoholism  and 
alcoholic  heredity.  His  record  at  school,  according  to 
acquaintances,  was  a  bad  one  as  regards  scholarship 
and  drinking  habits,  but  not  otherwise. 

The  neurotic  paralysis  that  resembles  paresis,  the  alco- 


2l6  THE    TOXIC    INSANITIES. 

holic  pseudo-paresis,  may  appear  as  an  episode  of  chronic 
alcoholism,  or  may  be  the  result  of  a  continued  spree  in 
individuals  not  habitual  drunkards.  In  this  last  case  it 
is  often  of  short  duration,  and  might  be  considered  as  a 
form  of  acute  alcoholism,  but  cases  are  rather  rare,  and 
are  noticed  here  with  the  more  common  form  occurring 
in  the  course  of  chronic  alcoholic  dementia.  Convul- 
sions and  apoplectiform  attacks  have  been  noticed  in 
connection  with  both  these  forms  of  alcoholic  paralysis, 
and  an  elaborate  differential  diagnosis  is  made  by  Regis 
between  alcoholic  pseudo-paresis  and  the  genuine  form. 
The  real  distinctions,  however,  and  the  ones  most  to  be 
relied  on,  are  the  etiologic  relations  and  the  usual  tem- 
porary nature  of  the  alcoholic  type. 

Something  might  be  said  here  of  dipsomania,  which 
has  already  been  mentioned  as  a  special  degenerative 
type  of  alcoholic  insanity.  It  falls  more  properly, 
however,  under  the  head  of  degenerative  than  toxic 
insanities,  and  will  be  considered  elsewhere  with  other 
types  of  periodic  morbid  impulse. 

In  conclusion,  it  may  be  said  here  that  not  all  in- 
sanities caused  by  alcohol,  or  in  which  it  is  an  etiologic 
factor,  are  to  be  counted  among  the  alcoholic  insanities. 
We  have  considered  in  this  chapter  only  those  forms 
that  present  certain  special  characters,  either  in  their 
symptoms  or  their  mode  of  origin,  entitling  them  to  be 
called  alcoholic.  Any  powerful  neurotic,  for  alcohol 
can  be  called  such,  is  liable  to  disorder  an  unstable 
brain,  apart  from  its  immediate  intoxicating  effects. 
Its  protracted  usage  is  still  more  damaging  in  this  way, 
and  many  cases  of  insanity  occur,  due  more  or  less 
directly  to  this  cause,  in  which  the  etiologic  factor  is 
not  necessarily  prominent  either  in  the  clinical  symp- 
toms or  the  pathologic  lesions.  Such  cases  are  not 
recognized  as  alcoholic  insanity,  and  they  compose  the 
larger  proportion  of  the  10  to  20%  of  insanities  that 
can  be  attributed  to  this  cause. 


CHRONIC    ALCOHOLIC    INSANITY.  21 7 

Pathology. — Alcohol  is  classed  popularly  as  a  stimu- 
lant, and  it  does  have  this  action  in  a  transitory  way, 
but  its  most  striking  effect  is  as  an  anesthetic  and  a 
vasomotor  depressant,  producing  degenerative  changes 
in  the  neurons  and  connective  tissue  of  the  brain,  and 
in  the  heart,  arteries,  liver,  and  kidneys.  The  gross 
changes  found  in  the  nerve-centers  consist  largely  of 
neuritis,  atheroma  and  fatty  degeneration  of  the  blood- 
vessels, thickening  of  the  membranes,  inflammatory 
adhesions  of  the  cortex  and  meninges,  discoloration, 
effusions  in  the  ventricles,  and  hemorrhagic  foci,  etc. 

The  prognosis  of  acute  alcoholism  is  favorable  as 
far  as  the  immediate  attack  is  concerned.  Chronic 
alcoholism  is  not  a  promising  condition  as  regards 
even  temporary  recovery ;  and  if  improvement  occurs, 
relapses  are  the  rule.  The  prognosis  in  chronic  alco- 
holic dementia  is  bad. 

Treatment. — Acute  alcoholism  is  benefited  by  the 
use  of  such  rapidly  diffusible  stimulants  as  liq.  ammonii 
acetatis  in  2 -dram  (8.00)  doses  every  two  hours  during 
the  day,  with  an  abundance  of  easily  digestible  food, 
of  which  koumiss,  peptonized  milk,  and  the  various 
predigested  preparations  of  beef  are  examples;  all  the 
food  the  patient  can  possibly  be  induced  to  take  and 
assimilate  should  be  given.  Eight  hours  sleep  in  the 
twenty-four  should  be  secured,  and  for  this  purpose 
chloralose  in  15 -grain  (1.010)  doses  is  the  most  reliable, 
and  should  be  used  unless  the  enfeebled  circulation 
contraindicates  it;  then  sulphonal  in  20-grain  (1.33) 
doses,  with  hyoscin  hydrobromate,  gr.  yJ^j  (0.00067), 
or  chloralamid,  20  grains  (1.33),  or  trional,  20  grains 
(1.33),  or  chloral,  15  grains  (1.00),  to  be  repeated  in 
one  hour  if  sleep  does  not  follow.  With  the  treatment 
by  diffusible  stimulants,  food,  and  sleep  may  be  used 
with  advantage  strychnin  sulphate,  gr.  ^  (0.002), 
once  in  six  hours  by  the  mouth.  For  the  chronic  form, 
alteratives  are  necessary  in  addition  to  tonics. 


2l8  THE    TOXIC    INSANITIES. 

The  iodid  of  potassium,  sodium,  or  strontium  in 
moderate  doses,  the  hydrarg.  chlorid.  corrosiv.,  or  the 
auri  et  sodii  chlorid.,  all  have  some  therapeutic  power 
to  diminish  the  rate  of  degeneration  in  the  neurons, 
and  to  correct  in  part  that  which  has  taken  place.  Of 
these  alteratives,  the  preference  is  for  the  auri  et  sodii 
chlorid.,  combined  with  resina  guaiac. — a  combination 
that  is  synergistic,  and  one  that  does  not  decompose 
the  gold  salt ;  ^  grain  to  \  grain  (0.003  to  0.008)  of  the 
gold  salt,  with  3  grains  to  5  grains  (0.18  to  0.30)  of  the 
guaiac,  may  be  given  one  hour  before  meals. 

In  the  chronic  form  strychnin,  quinin,  ferrum,  and 
arsenic  may  with  advantage  be  combined  with  the 
alteratives,  the  abundant  feeding,  and  the  hypnotics. 

In  the  treatment  of  the  alcoholic  insane  attention 
must  be  given  to  elimination  by  bowels,  kidneys,  and 
skin.  The  Turkish  bath  with  massage  is  the  ideal 
way  of  promoting  the  skin  elimination,  and  small  doses 
of  hydrarg.  chlorid.  mitis,  gr.  1  or  2  (0.006  to  0.0012) 
in  divided  doses,  will  usually  give  free  elimination  by 
bowels  and  kidneys.  The  action  of  the  bowels  may 
subsequently  be  maintained  by  the  use  of  aloetics. 
An  excellent  combination  is  ext.  aloes,  gr.  1  to  2  (0.06 
to  0.12) ;  pulv.  ipecac,  gr.  -^  (0.006) ;  ext.  hyoscy.,  gr. 
1  (0.06),  at  bedtime;  and  the  kidney  action  may  be 
maintained  by  the  use  of  water  with  or  without  an 
alkaline  diuretic,  such  as  the  citrate  or  acetate  of 
potassium  in  10-grain  doses  (0.66). 

In  the  treatment  of  both  forms  of  alcoholic  insanity 
the  administration  of  alcohol  is  contraindicated. 

The  confirmed  inebriate  can  be  really  cured  only  by 
removing  from  him  all  possibility  of  obtaining  liquor 
or  by  strengthening  his  will-power  in  some  way,  pref- 
erably by  some  strong  moral  impulse,  religious  or  other- 
wise. The  various  cures  that  are  so  much  vaunted  at 
the  present  time  operate  largely  in  this  way;  they  aid 
the  victim's  own  desire  to  rid  himself  of  his  habit  by 


MORPHINISM.  219 

creating  a  temporary  disgust  for  the  liquor,  and  enforce 
it  by  suggestion  and  mutual  encouragement.  Tem- 
perance societies  and  revivals  act  in  similar  ways. 
Institutions  for  the  care  and  cure  of  inebriates  may  be 
very  useful,  especially  if  they  can  exercise  legal  control 
over  them  for  the  necessary  period  of  treatment,  and 
they  should  not  be  luxurious  retreats  for  loafers,  but 
places  where  work  and  discipline  are  enforced.  With 
suitable  occupation,  wisely  supervised,  due  restraint 
and  discipline,  and  proper  medical  care,  such  establish- 
ments probably  would  afford  one  of  the  best,  if  not  the 
very  best,  means  for  treatment  of  the  semi-insanity 
and  weakened  inhibitions  of  inebriety. 

MORPHINISM. 

Next  to  alcohol,  opium  and  its  derivatives  are  re- 
sponsible for  the  highest  number  of  cases  of  drug  in- 
sanity. Their  effects  are  so  agreeable  in  the  beginning 
of  their  use,  and  have  been  so  largely  employed  to 
alleviate  pain,  that  it  is  not  surprising  that  the  habit 
of  their  usage  grows  on  their  victims  till  in  the  end 
mental  derangement  is  the  result.  The  stress  of  life 
at  the  present  time  favors  the  development  of  neu- 
rotic tendencies,  and  these,  in  turn,  give  rise  to  drug 
and  alcoholic  habits,  the  former  not  less  serious  in  their 
consequences  to  their  victims  than  the  latter. 

The  opium,  or  more  commonly  the  morphin,  habit 
may  often  originate  from  its  medical  prescription  for 
the  relief  of  pain,  but  it  is  also  often  started  inde- 
pendently or  from  association  with  other  habitues.  The 
latter  factor  is  most  evident  in  the  opium-smoking  habit 
introduced  from  the  East,  which  prevails  to  a  greater 
extent  than  is  generally  known  amongst  certain 
classes  in  the  large  cities.  The  commoner  habit  of 
morphin  using,  by  the  mouth  or  hypodermically,  is, 
however,  responsible  for  the  great  majority  of  the 
cases  of  actual  insanity  from  these  drugs. 


220  THE    TOXIC    INSANITIES. 

The  ordinary  form  of  mental  disorder  from  opium  is, 
like  that  from  alcohol,  a  weakening  of  the  will-power,  a 
lack  of  moral  inhibition  and  of  physical  energy.  The 
victim  becomes  indolent  or  irregular  in  his  exhibitions 
of  activity;  unreliable,  untruthful,  and  sometimes 
actively  depraved,  indulging  in  outrageous  excesses. 
In  addition  we  ma}^  see  sometimes  actual  delusions 
and  dangerous  morbid  impulses  manifest  themselves. 
Morphin  habitues,  like  alcoholics,  differ  widely  as 
regards  the  effect  of  the  drug;  some  appear  to  be  to  a 
great  extent  immune  to  the  bad  effects  of  the  drug, 
but  in  this  country  these  are  the  exceptions.  A  final 
result  of  the  morphin  habit  is  actual  insanity,  gener- 
ally, so  far  as  we  have  observed  it,  of  the  depressed  or 
melancholic  type,  but  which  has  'not  always  charac- 
teristic features  indicating  its  origin. 

The  physical  symptoms  of  the  morphin  habit  are 
numerous — increased  sensibility  and  irritability,  loss 
of  appetite  and  body-weight,  insomnia,  loss  of  sexual 
power,  etc.  The  intoxication  is  not,  like  that  of 
alcohol,  a  motor  one;  the  subjects  are  quieter,  not  up- 
roarious or  dangerous,  as  a  rule.  The  deprivation  of 
the  accustomed  dose  is  accompanied  with  aggravated 
symptoms,  sometimes  vomiting,  purging,  extreme 
restlessness,  bodily  pains,  sometimes  hallucinations  of  a 
terrifying  nature,  all  most  intense  for  a  brief  period, 
and  in  some  cases,  where  the  heart  is  not  sound,  fatal 
syncope  may  occur. 

A  morphin  habitue  may  confine  his  indulgence  to  it 
alone,  but  it  is  almost  the  rule  that  other  intoxicants 
or  drugs  are  also  used.  This  is  becoming  more  common 
of  late  years;  formerly,  the  contracted  pupils  were  a 
diagnostic  sign  of  the  habit,  but  latterly  the  use  of 
atropin  with  the  morphin  is  so  common  that  it  is  no 
longer  reliable.  The  morphinist  may  also  be  a  sot,  a 
cocain  user,  a  slave  to  the  chloral  or  other  habits. 
Opium,  as  is  well  known,  induces  a  certain  tolerance 


MORPHINISM.  221 

to  its  effects,  and  the  tendency  is  therefore  to  steadily 
increase  the  daily  dose  taken;  of  morphin  a  dram  or 
more  may  be  reached  daily,  or  the  subject  may  use  as 
many  as  a  dozen  or  even  more  hypodermic  doses  each 
day,  or  drink  laudanum  by  the  ounce.  Even  with  these 
habits  it  is  not  always  easy  to  make  a  certain  diagnosis 
in  all  cases  from  mere  appearances,  though  there  is  a 
certain  opium-eater  physiognomy  and  complexion — a 
peculiar  pallor — that  may  lead  to  a  suspicion  of  the 
habit  in  many  cases.  A  urinary  examination  may 
reveal  the  drug  to  the  tests  and  thus  aid  the  diagnosis. 

The  prognosis  of  morphinism  is  generally  a  serious 
one,  and  especially  if  actual  insanity  is  its  result. 
The  melancholia  of  opium-eaters  has  not,  in  the  few 
cases  we  have  observed,  been  readily  relieved,  though 
the  morphin  habit  was  checked.  In  cases  that  reach 
only  the  semi-insanity  of  the  confirmed  opium  fiend, 
while  the  habit  may  be  broken  off,  the  danger  of  a 
relapse  is  always  to  be  considered.  Opium  or  morphin 
habitues  are  notoriously  unreliable,  and  the  habit  is 
likely  to  be  resumed  in  secret  when,  according  to 
appearances,  everything  is  progressing  well.  They  are 
also  notoriously  cunning  in  their  plans  to  obtain  the 
drug,  and  the  closest  watchfulness  is  required  on  the 
part  of  those  who  have  to  care  for  them.  These  facts 
should  make  one  cautious  in  offering  any  opinion  as  to 
a  permanent  cure  in  any  given  case.  While  it  is  said 
that  in  India  the  habitual  use  of  morphin  does  not 
shorten  life  (a  dubious  statement),  and  instances  of 
centenarian  opium-eaters  have  been  reported,  there  is 
little  question  that  the  habit  is  disastrous  in  leading 
to  less  vital  resistance  and  an  earlier  death. 

The  two  most  useful  drugs  for  relieving  the  prominent 
symptoms  of  morphinism  are  strychnin  sulphate  and 
atropin  sulphate.  The  strychnin  should  be  given  in 
gr.  g1^  doses  (0.02)  every  four  to  six  hours;  the  atropin, 
gr.    yi-g-    (0.0005)    twice   daily.     The   fluid   extract   of 


222  THE    TOXIC    INSANITIES. 

erythroxylon  in  i-dram  (4.00)  doses  is  of  considerable 
service  in  relieving  symptoms. 

The  morphin  should,  as  a  rule,  in  private  practice 
be  gradually  withdrawn;  it  is  in  many  cases  a  grave 
mistake  to  stop  it  abruptly,  though  this  is  practicable 
and  time-saving  in  robust  individuals  with  sound  cir- 
culatory organs  in  an  asylum  where  full  control  and 
ample  assistance  in  the  way  of  attendants,  etc.,  can 
be  had. 

Much  difficulty  will  often  be  encountered  by  reason 
of  the  derangement  of  the  gastro-intestinal  tract.  The 
food  should  be  given  in  the  greatest  abundance  pos- 
sible, and  often  should  be  predigested.  Eggnog  is 
often  the  best  food  that  can  be  used,  and  four  to  six  of 
these,  each  containing  one  egg  and  a  glass  of  milk,  may 
be  given  in  twenty-four  hours.  Attention  should  be 
given  to  elimination  by  skin,  kidney,  and  bowels ;  the 
hot  bath  and  massage,  the  alkaline  diuretics,  with 
tinct.  digitalis,  and,  if  the  bowels  are  loose,  the  sub- 
gallate  of  bismuth  in  15-grain  doses  (1.00)  every  two 
or  three  hours;  if  they  are  constipated,  the  aloetic 
laxatives  may  be  used. 

It  is,  moreover,  important  in  these  cases  to  secure 
a  reasonable  amount  of  sleep,  and  this  may  be  done  by 
the  method  already  described  under  Alcoholic  Insanity. 

According  to  Kane,  the  opium-smoking  habit,  while 
the  most  disastrous  morally  and  financially  of  all  the 
opium  habits,  is  the  least  so  to  the  physical  health,  and 
the  easiest  to  cure.  He  advises  the  use  of  capsicum, 
digitalis,  and  cannabis  indica  in  large  doses,  frequently 
repeated;  the  bromids  to  relieve  nervous  symptoms, 
used  cautiously,  however,  and  only  for  a  very  few  days 
at  the  most;  bismuth,  etc.,  for  the  diarrhea  and  vomit- 
ing; chlorid  of  gold  and  soda,  -^  grain  (0.003)  every 
two  hours ;  with  fluid  extract  of  gelsemium  to  relieve 
pains  in  the  limbs;  massage;  hot  baths;  tonics,  etc., 
and  special  remedies  as  indicated  to  produce  sleep  and 


COCAINISM.  223 

relieve  bronchial  irritation.  Out-of-door  exercise  and 
steady  occupation  under  watchful  supervision,  pref- 
erably in  an  institution,  are  necessary  adjuncts. 

COCAINISM. 

Erythroxylon  coca  and  its  alkaloid  cocain,  especially 
the  latter,  are  among  the  most  dangerous  of  all  the 
drugs  that  enslave.  It  is  said  that  the  use  of  cocain  is 
increasing,  and  that  cases  of  insanity  due  to  it  are 
becoming  more  numerous.  Its  effects  on  the  brain  and 
nervous  system  are  such  as  to  make  it,  if  anything, 
more  tempting  even  than  morphin,  while  its  hold  on  the 
system  is  fully  as  great  when  the  habit  is  once  estab- 
lished. There  is  hardly  any  drug  that  so  quickly 
drives  away  care  and  produces  a  feeling  of  well-being 
and  satisfaction,  or  that  more  insidiously  leads  to  exces- 
sive indulgence,  and  finally  to  mental  derangement,  as 
cocain.  The  mental  manifestations  of  cocain  insanity 
are  often  complicated  with  those  of  other  drugs  habit- 
ually used,  especially  morphin,  for  cocain  habitues  are 
very  commonly  morphin  fiends  also.  Victims  of  cocain 
alone,  however,  are  apparently  more  like  those  of  alcohol 
than  are  those  of  morphin,  and  they  are  attended  with 
somewhat  similar  physical  and  sensory  phenomena — 
partial  tremors,  hallucinations,  insomnia,  muscular  rest- 
lessness, and  even  incoordination.  The  patient  has  hal- 
lucinations in  many  ways  similar  to  those  of  alcoholic 
delirium,  and  yet  the  conditions  are  hardly  likely  to  be 
confounded.  Mentally,  the  manifestations  are  irrita- 
bility, violent  impulses,  change  of  character  and  fre- 
quently moral  depravity,  loss  of  will-power,  foolish 
actions  and  speech,  change  of  disposition  and  affec- 
tions, so  that  not  infrequently  there  arises  antagonism 
between  nearest  friends,  husband  and  wife,  parents 
and  children.  There  is  a  cocainic  paranoia  of  jealousy 
with  delusions  of  mental  infidelity,  suggesting  that 
from  alcohol,  and  closely  resembling  it.     The  intellect 


224  THE    TOXIC    INSANITIES. 

and  memory  only  fail  later  in  these  cases,  but  the 
nervous  breakdown  is  inevitable,  and  finally  complete. 

The  diagnosis  is  difficult  without  a  knowledge  of  the 
cocain  habit,  but  this  generally  reveals  itself  to  close 
observation.  The  prognosis  of  chronic  cases  is  not 
good,  and  if  temporary  cure  is  obtained  the  danger  of 
relapses  is  ever  to  be  considered. 

Relapses. — Treatment. — The  drug  should  be  gradu- 
ally withdrawn.  Strychnin  sulphate  should  be  given 
in  about  -^--grain  (0.002)  doses  every  four  or  six  hours, 
with  abundance  of  easily  digestible  food.  Careful 
attention  should  be  given  to  elimination  by  skin,  kid- 
neys, and  bowels,  and  a  reasonable  amount  of  sleep 
should  be  secured  by  the  method  already  described 
under  alcoholism. 

The  patient,  as  well  as  the  morphin  and  alcoholic 
habitues,  should  be  kept  under  restraint  for  the  longest 
possible  time  after  apparent  recovery,  in  order  that 
the  best  opportunity  should  be  had  to  invigorate  the 
nervous  system,  so  as  to  give  them,  if  possible,  the 
necessary  power  of  resistance  against  the  tempting 
qualities  of  these  insidious  drugs. 

OTHER  DRUG  INSANITIES. 

Other  forms  of  mental  disorder  from  toxic  agents  are 
those  from  lead-poisoning,  chloral,  ether,  mercury, 
iodoform,  carbonic-acid  poisoning,  etc.  Insanity  from 
plumbic  intoxication  has  been  noticed  largely  by 
French  authors,  some  of  whom  recognize  a  pseudo- 
paresis  from  this  cause.  The  regular  symptoms  of  lead- 
poisoning  aid  in  the  diagnosis  in  these  cases,  which  are 
possibly  more  common  than  is  generally  supposed,  or 
perhaps  we  can  more  safely  say  that  this  etiologic  ele- 
ment enters  more  largely  into  the  causation  of  insanity 
than  is  sometimes  suspected.  A  certain  degree  of 
lead-poisoning  is  not  an  infrequent  occurrence,  as  any 
practitioner  can  testify,  especially  in  this  time,  when 


OTHER    DRUG    INSANITIES.  225 

lead  pipes  are  extensively  used  in  the  water  fixtures 
about  dwellings.  Lead-poisoning  is  often  overlooked 
in  cities  like  Chicago,  for  example,  where  the  water- 
supply  to  the  houses  is  by  means  of  lead  pipes,  and  the 
water  pressure  undergoes  frequent  variation  to  such  an 
extent  that  not  infrequently  water  cannot  be  drawn 
in  upper  stories.  Much  plumbic  oxid  is  formed  that 
may  be  imbibed  with  the  water,  and  little  by  little  in 
this  seemingly  mysterious  manner  plumbism  is  de- 
veloped ;  peripheral  neuritis,  arterial  degeneration,  and 
sclerosis,  one  or  all,  may  speedily  follow  and  mental 
derangement  ensue.  The  condition  of  the  emotions 
may  be  depression  or  exaltation,  followed  by  mental 
enfeeblement.  The  diagnosis  is  not  always  easy,  unless 
the  blue  line  pathognomonic  of  plumbism  develops. 

The  indications  for  treatment  are  to  secure  elimina- 
tion of  the  lead  by  cautiously  administering  iodids, 
rest,  food,  and  moderate  stimulation. 

Chloral  Insanity.— Chloral  insanity  is  much  less 
common  than  the  drug  insanities  already  described, 
yet  such  cases  are  too  frequently  met  with.  One 
characteristic  of  the  age  we  live  in  is  the  common  prev- 
alence of  insomnia.  The  restless  brain  activity  of  so 
many  people;  the  long  hours  of  brain  working;  the 
crowding  of  people  into  cities,  and  the  great  amount  of 
preventable  noises  in  cities;  the  prevalence  of  indiges- 
tion from  poorly  prepared  and  hastily  eaten  meals,  all 
contribute  to  the  common  condition ;  and  to  relieve  it 
many  resort  to  chloral,  undoubtedly  one  of  the  best 
hypnotics  we  possess,  and  little  by  little  they  drift  into 
the  chloral  habit,  and  they  suffer  from  the  depressing 
influence  of  the  drug  on  respiration,  circulation,  and 
the  general  nutrition;  and,  with  it,  mental  deteriora- 
tion, that  may  manifest  itself  either  in  maniacal  ex- 
citement or  melancholic  depression,  but  in  either  case 
with  a  gradually  developing  fatuity. 

Diagnosis. — This  drug  has  such  a  powerful  effect  as 
15 


226  THE    TOXIC    INSANITIES. 

a  depressant  that  the  depressed  condition  of  respiration 
and  circulation  will  aid  in  diagnosis,  but  the  history  of 
the  case  must  be  the  most  important  element. 

The  prognosis,  like  the  other  forms  of  drug  insanity, 
is  always  uncertain,  not  so  much  as  to  relief,  but  as  to 
permanency  of  cure. 

Treatment. — The  indications  for  treatment  are  to 
relieve  the  depression  and  improve  general  nutrition. 
The  drug  should  be  stopped  immediately.  Strychnin, 
cocain,  and  hyoscin  hydrobromate  are  useful  drugs, 
the  first  to  overcome  the  general  depression,  the  second 
and  third  to  relieve  the  general  nervousness  and  pro- 
mote sleep.  The  same  attention  should  be  given  to 
abundant  feeding,  and  to  elimination,  as  mentioned 
under  the  other  forms  of  this  class. 

Iodoform  Insanity.- — The  excellent  results  obtained 
by  surgeons  with  this  drug  as  a  dressing  for  wounds, 
and  its  supposed  harmlessness,  have  led  to  its  very 
general  and  liberal  use.  Two  or  three  drams  of  the 
powder  has  been  not  an  uncommon  amount  used  at  a 
single  dressing.  The  wounds  healed  kindly,  but  the 
patient  developed  so-called  traumatic  delirium,  post- 
operative insanity,  or  died  of  so-called  surgical  shock. 

The  iodoform  was  rapidly  absorbed  and  converted 
into  iodin;  the  body  soon  became  saturated,  and  the 
effects  were  largely  manifested  on  the  nervous  system 
— first  mental  depression,  then  wild  delirium,  and 
finally  acute  dementia.  Professor  Nicholas  Senn  early 
observed  these  disastrous  effects,  and  speedily  called 
the  attention  of  the  profession  to  them,  and  the  result 
has  been  a  very  much  more  cautious  use  of  the  powerful 
drug.  The  great  characteristic  of  iodoform  insanity  in 
the  early  stage  is  depression,  not  only  mental,  but 
physical,  and  alcoholic  stimulants  freely  used  are  in- 
dicated, together  with  attention  to  rest,  food,  sleep, 
and  elimination. 

The  other  drug  insanities  are  comparatively  infre- 


OTHER    DRUG    INSANITIES.  227 

quent.  In  some  parts  of  Ireland,  where  a  cheap  com- 
mercial ether  is  used  for  the  sake  of  its  intoxicating 
effects,  insanity  is  said  to  be  occasionally  the  result, 
and  a  few  cases  have  been  reported  in  this  country. 
Hashisch,  or  "bhang,"  a  preparation  of  cannabis 
indica,  is  stated  to  be  responsible  for  occasional  insane 
furor  in  the  natives  of  the  Malay  archipelago.  Any 
powerful  narcotic  or  stimulant,  or  otherwise  neurotic 
drug,  may,  if  used  to  excess,  disorder  the  nerve-centers 
and  produce  derangement,  but  the  most  of  such  cases 
are  best  regarded  as  only  of  etiologic  interest,  and  not 
as  affording  the  basis  for  new  types  in  the  classification 
of  insanity. 


CHAPTER  XIII. 
GENERAL  PARESIS,  PARETIC  DEMENTIA, 

Definition. — General  paresis,  or  paretic  dementia,  is 
a  disease  of  the  nervous  system,  and  particularly  of  the 
brain,  occurring  during  the  active  periods  of  life,  char- 
acterized on  its  psychic  side  by  a  usually  marked  and 
generally  progressive  dementia,  ordinarily  attended 
with  more  or  less  unsystematized  delusions  and  an  ex- 
pansive or  a  depressed  emotional  condition ;  and  on  its 
physical  side  by  gradually  increasing  motor  paresis 
and  various  irritative  and  paralytic  motor  and  sen- 
sory phenomena,  the  whole  tending  to  terminate  in 
more  or  less  complete  dementia,  motor  and  sensory 
paralysis,  and  death. 

The  above  definition,  lengthy  as  it  is,  does  not  by 
any  means  cover  all  the  phases  of  this  protean  disorder, 
but  simply  states  in  a  general  way  the  leading  features 
of  the  more  commonly  observed  types  of  the  disorder. 
There  are  exceptional  cases,  as  will  be  seen  when  the 
mental  symptoms  are  nearly  absent,  and  there  are 
others  that  are  carried  off  the  scene  by  convulsive  or 
paralytic  accidents  before  the  usual  motor  symptoms 
have  made  themselves  at  all  prominent.  These  will 
be  discussed  when  describing  the  symptomatology  of 
the  disorder.  The  disease  is  one  of  mature  life,  not 
one  of  old  age,  though  the  organic  dementias  of  ad- 
vanced life  may  simulate  it  in  some  respects.  Nor 
is  it  a  disorder  of  early  life ;  the  cases  in  which  it  appears 
before  full  bodily  maturity  are  exceptional. 

History. — The  recognition  of  paretic  dementia  as  a 
disease,  aside  from  some  vague  mention  of  certain  of 
its  symptoms  by  earlier  authors,  dates  back  less  than 

228 


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ETIOLOGY.  229 

eighty  years,  to  the  publications  of  Bayle,  in  1822,  and 
Calmeil,  in  1826.  Since  that  period  its  investigation 
was  for  a  number  of  years  largely  confined  to  the 
French  alienists,  but  within  the  last  three  or  four 
decades  it  has  been  the  most  extensively  studied  of  all 
the  forms  of  mental  disorder.  At  present  its  literature 
is  greater  than  that  of  any  other  type  of  insanity;  it 
has  been  written  upon  in  every  aspect,  and  the  number 
of  articles  now  appearing  upon  it  or  some  of  its  phases 
probably  equals  or  exceeds  that  of  those  upon  any 
other  two  species.  At  the  present  time  it  offers  as 
many  open  questions  for  discussion  as  ever. 

Notwithstanding  this  extensive  literature,  its  general 
recognition  in  asylums  is  a  comparatively  recent  thing, 
and  up  to  within  twenty  years  there  were  institutions 
that  never  reported  it  in  their  classification,  not  because 
they  did  not  receive  cases,  but  because  they  were  not 
so  diagnosed.  While  there  has  been  an  increase  in  its 
frequency  beyond  any  question,  it  is  also  true  that  this 
increase  for  many  years  was  magnified  by  the  fact  that 
cases  before  undiagnosed  were  beginning  to  be  recog- 
nized. At  the  present  time  it  has  everywhere  gained 
recognition,  and  is  one  of  the  forms  of  mental  disease 
that  is  best  known,  by  name  at  least,  even  by  the 
general  public. 

Etiology. — Paretic  dementia,  as  an  increasingly  fre- 
quent disease,  has  had  much  attention  given  to  its 
etiology,  and  to-day  it  has  a  rich  literature  upon  this 
point  alone.  At  the  present  time  the  prevailing 
opinion  amongst  alienists  is  probably  that  in  the  vast 
majority  of  cases,  if  not  in  all,  it  has  as  an  antecedent 
syphilitic  infection,  either  inherited  or  acquired.  This 
view  has  been  steadily  gaining  ground  within  the  past 
eight  or  ten  years,  and  appears  likely  to  be  soon  univer- 
sally accepted.  The  exact  causal  relation  of  syphilis  to 
the  disease  is  even  yet  not  perfectly  clear,  and  it  is  looked 
upon  rather  as  preparing  the  ground  than  as  a  direct  ex- 


230  GENERAL    PARESIS,    PARETIC    DEMENTIA. 

citing  cause.  It  is  still  contested  by  some  writers,  but 
their  arguments  are  based  upon  apparently  imperfect  ob- 
servation. It  must  be  remembered  that  a  history  of 
syphilis  is  not  always  easily  obtained,  and  that  statistics 
are  more  likely  to  err  on  the  side  of  its  non-existence  than 
on  the  other.  In  spite  of  this  fact,  however,  carefully 
studied  histories,  using  all  possible  reliable  data,  have 
shown  that  positive  proof  of  prior  syphilis  canbe  obtained 
in  70%  to  80%  of  the  cases,  and  its  probable  occurrence 
be  reasonably  inferred  or  suspected  in  a  large  propor- 
tion of  the  remainder.  The  small  percentage  remaining 
is  most  safely  left  under  the  head  of  "not  proven,"  as 
absolute  proof  of  the  absence  of  earlier  syphilis  is  com- 
monly out  of  the  question  as  much  as  is  that  of  its 
occurrence. 

It  has  been  said  that  syphilis  is  not  usually  a  direct 
cause ;  in  most  cases  it  antedates  the  disease  from  five 
to  twenty  years,  or  even  more.  It  is,  in  fact,  long  after 
any  manifestations  of  the  lues  have  disappeared  that 
paresis  begins ;  it  has,  therefore,  been  considered  not  as 
a  late  tertiary  or  quaternary  syphilitic  condition,  but 
rather  as  a  parasyphilitic  disorder,  one  in  some  way 
dependent  upon  the  prior  specific  disease,  but  not  ex- 
actly the  same  in  its  essential  nature.  There  are,  how- 
ever, cases  of  the  disease,  undistinguishable  from  it 
clinically,  and  sometimes  pathologically,  that  follow 
recent  syphilis  which  can  here  be  considered  as  an  ex- 
citing as  well  as  a  predisposing  cause.  It  seems  hardly 
correct  to  say,  therefore,  that  paresis  or  paretic  de- 
mentia is  exclusively  a  parasyphilitic  condition;  the 
less  so,  indeed,  since  we  sometimes  find  its  clinical 
syndrome  directly  associated  with  indubitable  luetic 
lesions,  gummata,  etc.,  of  the  brain.  To  say  that 
these  cases  are  not  paresis,  but  brain  syphilis,  is  beg- 
ging the  question ;  if  they  are  practically  indistinguish- 
able from  it  in  clinical  history,  progress,  and  termina- 
tion, they  are  certainly  paresis. 


ETIOLOGY.  231 

It  is  with  our  present  knowledge,  nevertheless,  safest 
to  admit  the  possibility  of  a  very  exceptional  non- 
syphilitic  causation  of  the  disorder.  Certain  toxic 
agencies,  other  than  specific  infection,  can  occasionally, 
as  we  sometimes  see,  produce  similar  symptoms  or 
conditions ;  but  there  are  generally  some  distinguishing 
points,  for  the  condition  thus  produced  is  a  temporary 
or  non-progressive  one.  There  is  some  reason  to  believe 
that  plumbic  intoxication  may  occasionally  give  rise  to  a 
paretic  dementia  which  is  hardly,  if  at  all,  distinguishable 
from  some  types  of  ordinary  paresis,  but  here  the  history 
will  aid  in  the  diagnosis,  and  even  then  it  may  not  be 
always  possible  to  exclude  luetic  infection.  It  is  not 
practicable  to  differentiate  them  always  by  the  fact  of  the 
curability  of  one  and  the  incurability  of  the  other,  for 
these  points  are  by  no  means  always  established.  An 
alcoholic  form  of  pseudo-paresis  is  not  infrequent,  but 
the  symptoms  are  generally  temporary,  and  the  type 
easily  distinguished. 

The  question  as  to  paretic  dementia  occurring  with- 
out antecedent  syphilis  can  best  be  left  as  follows :  In  a 
vast  majority  of  the  cases  of  paresis  we  can  demon- 
strate or  reasonably  assume  the  prior  occurrence  of 
syphilitic  infection.  In  a  very  small  proportion  of 
cases  it  cannot  be  positively  demonstrated,  and  may  be 
denied  in  all  the  history  of  the  case  that  is  available  or 
can  possibly  be  obtained.  There  is,  therefore,  left  an 
exceptionally  small  proportion  in  which  it  is  unproved, 
and  this  fact  alone  prevents  us  from  claiming  lues  as 
the  invariably  precedent  condition. 

Paretic  dementia  is  said  to  be  a  rare  or  unknown  dis- 
ease amongst  barbarians  and  uncivilized  races ;  notwith- 
standing the  very  great  prevalence  of  lues  among  the 
Hawaiians,  there  has  been  no  case  of  paretic  dementia 
in  a  full-blooded  Hawaiian  received  in  the  hospital  for 
insane  at  Honolulu  since  its  establishment.  It  is  cer- 
tainly more  frequent  the  higher  the  grade  of  civilization, 


232  GENERAL    PARESIS,    PARETIC    DEMENTIA, 

and  it  is  increasingly  frequent  in  modern  times.  There 
seems  to  be  something  in  the  stress  of  our  civilization 
that  favors  it,  and  while  some  of  the  apparent  increase 
may  be  due  to  its  better  recognition,  there  is  little 
question  but  that  it  is  becoming  more  frequent  than 
was  formerly  the  case. 

Age  has  been  noted  as  an  element  in  the  definition, 
but  more  should  be  said  on  this  point.  Paresis  is  essen- 
tially a  disorder  of  maturity,  not  of  adolescence  or  de- 
cadence. It  is  rare  before  the  age  of  twenty,  and 
almost  unknown  before  puberty ;  the  early  occurring 
cases  are  invariably  due  to  inherited  syphilis.  Its 
period  of  greatest  frequency  is  in  the  fourth  and  fifth 
decades  of  life;  it  is  rare  after  fifty,  and  though  cases 
are  reported  in  advanced  life,  between  sixty  and 
seventy,  these  are  more  probably  cases  of  organic 
senile  brain  disorder,  which  may  sometimes  resemble 
paresis.  It  is  preeminently  a  disorder  of  the  prime  of 
life ;  the  very  young  and  those  who  have  reached  middle 
age  are  more  rarely  its  victims. 

Males  are  more  subject  to  paresis  than  females,  but 
in  the  later  statistics  the  proportion  of  the  latter  is 
increasing.  The  ratio  between  the  sexes  has  been 
estimated  at  about  six  males  to  one  female,  but  some 
more  recent  Continental  figures  give  a  much  higher 
proportion  of  females — one  to  three  or  four.  The  in- 
crease of  paresis  among  women  is  largely  among  the 
lower  classes,  though  the  higher  are  not  exempt.  Pros- 
titutes are  especially  liable  to  the  disease,  and  of  those 
not  prostitutes,  married  women.  Of  the  three  un- 
married female  paretics  known  to  the  writer,  one  was  a 
prostitute,  one  had  evidently  borne  children,  though 
there  was  no  admission  or  history  of  it,  and  the  last 
was  a  waif  without  friends  or  history,  and  incapable 
of  giving  any  account  of  herself ;  the  only  known  fact 
that  had  any  possible  bearing  upon  her  past  was  that 
she  was  tattooed,  a  very  unusual  thing  in  females. 


ETTOLOGY.  233 

Occupation  has  its  influence  apparently  in  the  causa- 
tion of  paresis ;  the  disease  is  rare  in  clergymen,  as  has 
been  noted  in  foreign  statistics,  in  which  military 
officers  appear  as  paretics  in  undue  proportion.  In 
this  country,  if  any  class  of  workers  is  especially  liable 
to  this  disease,  it  appears  to  be  that  of  commercial 
travelers  and  railway  employees,  and  the  wives  of 
these  are  in  a  large  proportion  amongst  the  female 
paretics.  It  seems  to  affect  those  engaged  in  com- 
mercial pursuits  rather  more  than  professional  men  in 
our  observation.  It  has  been  said  that  it  is  a  disease 
of  the  higher  or  educated  classes  as  distinguished  from 
laboring-men  or  wage-workers,  but  this  is  not  strictly 
true,  for  it  affects  all  classes  without  regard  to  social  or 
financial  position  or  education,  and  this  fact  is  becoming 
more  evident  as  the  disease  becomes  more  frequent. 

It  has  been  said  that  certain  nationalities  or  races 
are  free  from  the  disease ;  the  Irish  in  Ireland  and  the 
Egyptians  have  been  mentioned  as  free  from  it.  The 
negroes  in  this  country  were,  it  is  said,  formerly  ex- 
empt, but  such  is  not  the  case  to-day.  In  this  country 
it  certainly  affects  all  nationalities. 

Heredity  figures  very  differently  in  different  statis- 
tics as  an  antecedent  or  causal  factor  of  this  disorder, 
some  authors,  like  Kraepelin,  neglecting  it  altogether 
in  this  connection,  while  others  give  it  a  greater  or  less 
importance.  Certain  French  authorities  lay  stress 
upon  a  congestive  as  opposed  to  a  vesanic  heredity,  the 
patient's  ancestors  having  suffered  from  congestive 
and  apoplectic  tendencies  rather  than  from  insanity 
strictly  so  called.  In  an  examination  of  between  two 
and  three  hundred  paretics  in  the  Eastern  Illinois 
Hospital  for  the  Insane  special  attention  was  given  to 
this  matter  of  heredity,  and  from  all  the  facts  that  could 
be  ascertained  it  appeared  that  there  was  only  about 
one-half  the  proportion  of  heredity  of  insanity  and 
nervous  diseases  among  the  paretics  that  existed  in  the 


234  GENERAL    PARESIS,    PARETIC    DEMENTIA. 

nonparetic  patients.  This  included  the  so-called  con- 
gestive heredity  so  far  as  could  be  ascertained,  as  well 
as  the  neurotic  and  vesanic  heredity.  In  one  patient 
there  was  an  apparent  direct  homologous  heredity  from 
father  to  daughter,  but  whether  this  was  a  genuine 
transmission  or  only  a  coincidence  cannot  be  positively 
stated.     There  are  few  such  cases  on  record. 

In  this  connection  may  be  mentioned  the  so-called 
conjugal  paresis,  husband  and  wife  both  having  the 
disease,  either  simultaneously  or  one  after  the  other. 
These  cases  are  not  so  uncommon ;  probably  every  large 
asylum  has  the  record  of  one  or  more.  In  the  cases 
observed  by  us  the  husband  was  generally  the  first 
affected,  the  wife's  disease  developing  later. 

Juvenile  general  paresis  is  also  well  known;  but,  as 
stated  above,  it  may  occur  at  any  period  after  the 
eleventh  or  twelfth  }^ear,  and  probably  even  earlier, 
but  most  cases  develop  about  puberty  or  a  little  later. 
It  is  invariably,  we  may  probably  say,  the  result  of  in- 
herited specific  disease. 

One  of  the  most  frequent  exciting  causes  of  this 
disorder  is  undoubtedly  mental  overstrain,  and  more 
especially  worry  and  anxiety.  Some  antecedent  of 
this  kind  is  found  in  a  very  large  proportion  of  all  the 
cases,  and  it  is  generally  put  down  under  the  head  of 
business  troubles  or  reverses,  or  sometimes  family 
troubles.  Other  common  apparent  exciting  causes 
are  excesses  of  various  kinds, — alcoholic,  sexual,  etc., — 
traumatisms,  head  injuries,  insolation  or  exposure  to 
excessive  heat  other  than  directly  from  the  sun,  etc. 
Intemperance  alone  has  been  considered  by  some  as 
the  chief  etiologic  factor;  others  have  joined  with  it 
sexual  excesses  and  worry,  the  often-quoted  etiologic 
tripod.  These  are  the  exciting  causes,  but  they  alone 
are  not  capable  of  producing  the  disease;  they  have 
existed  from  all  time,  but  paresis  is  a  comparatively 
modern  disorder.     We  must  assume  that  some  other 


ETIOLOGY.  255 

cause  exists,  either  in  the  condition  of  our  civilization 
or  in  the  civilized,  race  in  its  present  stage  of  develop- 
ment. It  seems  to  us  at  least  possible  that  a  partial 
explanation  may  be  found  in  the  demands  made  upon 
the  individual  by  the  present  environments,  and  the 
fact  that  many  who  in  former  years  would  have  lived 
a  quiet,  uneventful  life  are  now  thrown  into  surround- 
ings of  competition  and  stress  to  which  they  are  un- 
equal. In  other  words,  the  increase  of  general  paresis 
is  largely  due  to  the  excessive  demands  made  upon  the 
nervous  centers  in  the  conditions  of  modern  life  acting 
upon  a  brain  weakened  and  prepared  by  a  prior  infec- 
tion, in  the  vast  majority  of  cases  the  virus  of  syphilis. 
We  must  also  reckon  physical  as  well  as  psychic  strains ; 
the  frequency  of  this  disorder  and  spinal  degenerations 
amongst  railway  men,  for  example,  may  very  possibly 
be  due  to  the  shocks,  concussions,  and  strain  upon  the 
nervous  apparatus  by  railway  travel,  which,  singly 
imperceptible,  must  be  serious  in  the  aggregate  as  an 
exciting  cause. 

Summing  up  the  etiology  of  general  paresis,  we  have 
in  it  a  disease  that  may  unquestionably  follow  recent 
syphilis,  and,  according  to  the  best  statistics,  is  preceded 
in  from  70  to  90%  of  all  cases  by  syphilis;  that  is  ap- 
parently communicable  from  husband  to  wife ;  that  is 
most  common  in  great  centers  of  population  and  rare 
in  rural  districts.  It  occurs  at  an  early  age  only  in 
the  subjects  of  hereditary  syphilis.  This  disease  is 
particularly  frequent  in  the  classes  of  men  and  women 
who  are  especially  subject  to  venereal  disease,  and  rare 
in  those  who  from  their  profession  and  surroundings 
are  presumably  least  liable  to  be  thus  affected.  We 
find,  also,  that  the  antecedent  syphilis  in  paresis  is  not 
of  recent  date,  as  a  rule,  but  dates  back  from  five  to 
twenty  years,  and  that  the  period  of  its  greatest  fre- 
quency is  in  the  active  period  of  life — in  the  fourth  and 
fifth  decades,  after  the  system  has  fully  developed  and 


236  GENERAL    PARESIS,    PARETIC    DEMENTIA. 

before  the  period  of  decadence  has  set  in.  It  is  com- 
mon also,  we  find,  in  the  centers  of  modern  civilization 
and  rare  or  little  known  amongst  barbarians  or  savages. 
Its  direct  exciting  causes,  aside  from  the  predisposing 
one  of  toxic  infection  of  syphilis,  appear  to  be  mental 
overstrain  and  excesses;  and,  secondary  to  these  in 
importance,  traumatism,  insolation,  etc.  It  may  there- 
fore be  considered,  in  all  probability,  as  a  toxic  dis- 
ease, generally  due  to  the  toxin  of  syphilis ;  but  this  is 
called  into  action  only  by  special  conditions,  favored 
by  modern  civilization  and  rare  under  the  simpler  and 
less  complicated  environments. 

Symptoms. — The  beginnings  of  paresis  are  generally 
obscure,  and  hardly  ever  come  under  the  observation 
of  the  alienist.  In  a  very  large  proportion  of  cases  the 
first  symptoms  are  indistinguishable  from  those  of  neu- 
rasthenia. The  patient  feels  and  acts  as  if  suffering 
simply  from  nervous  exhaustion ;  he  feels  incapable  of 
doing  his  usual  amount  of  work ;  his  sleep  is  disturbed ; 
he  cannot  fix  his  attention  as  well  as  he  could ;  he  may 
watch  his  symptoms  carefully  and  worry  over  them  to 
the  detriment  of  his  actual  working  capacity.  Memory 
is  apt  to  show  signs  of  failure,  and  the  patient  makes 
mistakes,  and  does  not  correct  them  as  he  would  in  his 
normal  condition.  There  may  be  increased  irrita- 
bility, aggravated  by  the  patient's  own  recognition  of 
his  lapses  and  mistakes.  Sometimes  there  are  spells  of 
absence  of  mind  that  are  noticeable  to  friends,  who 
often  think  the  patient  is  suffering  from  overwork. 
With  these  psychic  changes  there  are  physical  symp- 
toms— headache  is  not  infrequently  complained  of,  the 
digestion  is  apt  to  be  deranged,  constipation  often 
exists,  the  subject  may  be  somnolent  during  the  day 
and  more  or  less  sleepless  at  night.  Occasionally  at 
the  early  stage  there  are  very  pronounced  and  serious 
nervous  symptoms.  The  first  thing  to  call  attention 
to  the  patient's  condition  may  be  a  convulsion  or  apo- 


SYMPTOMS.  237 

plectic  attack,  after  which  the  mental  and  physical 
deterioration  may  be  decidedly  more  marked.  In  one 
case  under  observation  the  first  noticeable  symptom 
was  an  apoplectic  attack  causing  temporary  hemiplegia 
followed  by  aphasia,  both  of  which  passed  off  within 
twenty-four  hours  or  a  little  more.  In  another  there 
was  a  pronounced  depression  for  a  few  weeks;  then 
aphasia,  followed  by  convulsions.  These  cases,  how- 
ever, are  rather  the  exception.  As  a  rule,  the  onset  is 
very  gradual  and  the  symptoms  often  hardly  distin- 
guishable for  a  long  time  from  those  of  one  of  the  pro- 
tean types  of  nervous  exhaustion.  There  is  often  a 
slight  but  somewhat  noticeable  change  in  the  facial 
expression,  a  sort  of  lack  of  expression,  that  occurs 
early;  but  this  is  not  usually  very  marked  till  a  later 
stage  of  the  disease.  This  is  probably  due  to  a  slight 
paresis  of  the  facial  muscles  that  becomes  more  marked 
as  the  disease  advances.  Other  symptoms  noticed  at 
this  stage  are  short  light  breathing  during  sleep,  varied 
by  occasional  long  expirations;  also  a  stiffness  of  the 
thorax  from  periostitis  of  the  sternum,  making  the 
respiration  almost  exclusively  abdominal  (Regis), 
ocular  disturbances,  myosis,  pupillary  inequality  or 
irregularity,  transient  amaurosis,  loss  of  pupillary  reflex 
to  light  (Argyll-Robertson  pupil),  exaggeration  or  loss 
of  knee-jerk,  cutaneous  anesthesia  and  hyperesthesia, 
ulnaris  analgesia,  etc.  When  we  consider  that  the  dis- 
order is  at  this  stage  an  incipient  chronic  meningo- 
encephalitis affecting  more  or  less  the  whole  convexity 
of  the  brain,  the  possibilities  in  the  way  of  bodily  and 
mental  symptoms,  if  closely  watched  for,  seem  almost 
infinite. 

As  the  disorder  advances  the  mental  symptoms  be- 
come more  marked,  the  loss  of  power  of  attention  in- 
creases, the  irritability  becomes  more  pronounced,  the 
patient  shows  some  change  of  character;  he  may  be 
moody   and    silent   or   exhilarated;   attention  to   the 


238  GENERAL    PARESIS,    PARETIC    DEMENTIA. 

ordinary  decencies  and  proprieties  of  life  is  relaxed. 
The  moral  character  suffers,  and  the  patient  may 
commit  some  crime  with  no  apparent  sense  of  hav- 
ing done  wrong.  Frequently  he  indulges  in  ex- 
travagances that  cause  his  friends  to  realize  he  is  not 
his  normal  self  and  to  take  measures  for  his  seques- 
tration. Paretics  in  this  stage  of  their  disease  are 
not,  as  a  rule,  dangerous  to  others;  but  if  their 
natural  disposition  is  unpleasant,  it  may  be  aggravated 
at  this  time  or  their  irritability  may  become  so  in- 
creased as  to  get  them  into  trouble  with  others.  In 
the  majority  of  cases  their  disposition  at  this  time  is 
generally  happy  and  exalted ;  in  a  minority  there  is  de- 
pression, and  hypochondriacal  symptoms  are  often  very 
marked.  The  intellect  may  appear  comparatively  clear 
till  many  of  the  symptoms  enumerated  above  are  quite 
manifest,  but  usually  there  is  very  apparent  mental  de- 
terioration manifest  before  the  close  of  this,  which  we 
may  call  the  first  or  prodromal  stage  of  the  disorder. 

In  a  small  proportion  of  cases  the  disease  begins  with 
spinal  symptoms,  and  a  diagnosis  of  locomotor  ataxia 
may  be  made  before  paresis  is  suspected.  The  writers 
have  known  of  more  than  one  case  in  which  this  oc- 
curred, the  ataxic  symptoms  later  disappearing  or 
becoming  so  slight  as  not  to  be  readily  perceptible  or 
to  be  masked  by  the  other  more  pronounced  paretic 
symptoms. 

The  speech  is  rather  early  affected  in  most  cases  of 
general  paresis,  and  its  defect  is  marked,  as  a  rule,  to 
an  experienced  observer  before  the  end  of  the  first  stage 
of  the  disease.  It  is  not  easy  to  describe  the  character- 
istics of  the  earliest  disturbance  of  speech ;  it  may  per- 
haps be  called  a  sort  of  thickness  of  articulation,  readily 
appreciated  when  once  heard,  but  difficult  to  specify 
how  it  differs  from  the  normal.  Later,  when  it  is 
more  marked,  its  characteristics  are  more  readily 
defined.     In  the  early  stage  it  is  almost  imperceptible, 


SYMPTOMS.  239 

but  a  trained  ear  can  often  recognize  it  at  once,  before 
there  is  any  such  embarrassment  of  articulation  as  to 
interfere  with  the  pronouncing  distinctly  of  the  most 
difficult  words  and  sentences.  A  tremor  of  the  lips 
and  tongue  can  be  detected  in  these  cases,  but  this 
does  not  fully  account  for  the  speech  defect,  which  is 
doubtless  partially  due  to  lesions  of  the  motor  center 
of  speech.  With  the  peculiar  articulation  there  is 
frequently  a  slurring  over  and  dropping  of  certain 
words  that  is  likewise  characteristic. 

The  principal  difficulty  appears  to  be  in  the  pro- 
nunciation of  the  labials  and  dentals  and  of  words  con- 
taining these.  "National  Intelligencer,"  "round  and 
round  the  rugged  rocks  the  ragged  rascal  ran,"  and 
such  single  words  as  "Mitchell,"  "artillery,"  etc.,  are 
good  tests  in  these  cases. 

The  writing  suffers  also,  and  even  more  strikingly 
than  the  articulation ;  it  becomes  markedly  tremulous, 
and  the  dropping  or  incompleteness  of  words  is  often 
noticeable.  This  also  may  appear  in  the  first  or  pre- 
liminary stage  of  the  disease,  though  it  is  then  but 
slight.  One  of  the  earliest  symptoms  noticed  in  one 
of  our  patients  was  his  failure  to  properly  perform  his 
work,  that  of  a  stenographer,  while  he  remained  rational 
in  conversation  and  behavior  for  months  after  he  had 
lost  his  position,  though  both  writing  and  speech  were 
apparently  affected.  In  another  case,  that  of  a  woman, 
her  speech  was  so  affected  as  to  make  it  difficult  for  one 
unaccustomed,  to  understand  her  at  all,  and  yet  she 
could  hardly  be  called  beyond  the  first  stage  of  the  dis- 
ease in  other  respects.  Such  a  case,  however,  is  excep- 
tional. 

In  a  few  cases  the  speech  defect  never  becomes  so 
marked  as  to  seriously  embarrass  articulation  till  very 
late  in  the  disease,  and  then  the  speech  is  lost  from 
the  general  dementia,  rather  than  from  any  paralysis 
of  articulation  itself. 


240  GENERAL    PARESIS,     PARETIC    DEMENTIA. 

A  prominent  feature  of  the  early  stage  of  paresis  in 
many  cases  is  sexual  excitement,  and  this,  with  the 
obtusion  of  the  moral  sense,  may  be  the  cause  of  serious 
crimes.  More  often  a  man  whose  character  before  was 
irreproachable  shocks  his  family  and  friends  by  in- 
decent or  lewd  behavior,  or  sometimes  by  a  complete 
reversal  of  his  former  character  in  this  respect. 
Others,  while  apparently  rational,  become  klepto- 
maniacs, utterly  disregardful  of  law  or  others'  rights  of 
property.  One  of  the  most  rational  paretics  in  the 
early  stage  of  the  disease  among  our  patients  was  a 
most  inveterate  and  cunning  thief,  a  fact  that  was  not 
discovered  until  after  his  death,  which  occurred  sud- 
denly in  an  apoplectic  attack. 

The  duration  of  this  first  stage  may  vary  from  a  few 
weeks  to  many  months.  Sometimes  it  cannot  be  said 
to  exist  at  all;  the  patient  may  have,  as  already  de- 
scribed, a  convulsion  or  apoplectic  attack  and  pass 
immediately  into  the  more  advanced  stage.  It  may 
terminate  in  death  from  convulsions,  or,  as  is  more 
rarely  observed,  in  acute  delirium.  Generally,  however, 
it  passes  into  the  second  stage  of  full  development. 

There  is  no  one  symptom  particularly  characteristic 
of  this  change,  but  it  is  marked  by  a  general  pronounced 
mental  and  physical  deterioration.  The  patient  who  pre- 
viously had  been  almost  or,  in  some  cases,  quite  rational, 
is  now  clearly  insane,  and  the  little  peculiarities  that 
have  perhaps  hardly  attracted  the  notice  of  his  friends 
are  becoming  pronounced  features.  The  slight  ex- 
travagances and  moral  slips  of  the  earlier  period  de- 
velop into  full-fledged  delusions,  not  fixed,  as  a  rule, 
but  characteristically  changeable  and  unsystematized. 
The  dementia  element  is  manifest;  the  patient  is  no 
longer  cognizant  of  his  disorder,  but  lives  in  an  unreal 
world  dominated  by  his  exalted  or  otherwise  affected 
emotions.  These  patients  are  kings,  queens,  or  what- 
ever their  prior  environment  and  education  has  taught 


SYMPTOMS.  241 

their  imagination  to  fancy.  The  delusions  are  reck- 
lessly extravagant:  a  man  may  one  minute  claim  to 
have  staked  out  a  mining  claim  over  a  vein  one  hundred 
feet  wide  of  coined  double  eagles ;  he  may  claim  to  have 
hundreds  of  wives  and  thousands  of  children,  and  a 
little  later  to  have  been  the  most  successful  missionary 
ever  known,  converting  and  baptizing  millions  of  the 
heathen  alone  and  unaided,  or  the  greatest  general, 
prize-fighter,  capitalist,  etc.  Much  depends  upon  the 
natural  vividness  of  the  imagination;  some  are  more 
quiet,  and  merely  manifest  a  happy  general  delusive 
tendency,  without  any  specially  exalted  ideas;  they 
fall  in  readily  with  the  notions  of  any  one  who  con- 
verses with  them,  and  while  not  less  fully  demented, 
are  less  actively  irrational.  In  many  cases  the  mental 
symptoms  consist  only  in  the  evidences  of  a  steadily 
but  gradually  increasing  dementia,  sometimes  happy, 
sometimes  apathetic  or  depressed.  The  patients  are 
never  actively  deluded,  but  they  show  their  mental 
weakness  in  every  way,  and  it  slowly  but  steadily  in- 
creases until  the  absolute  dementia  exists.  Still  others 
are  actively  depressed;  their  delusions  have  often  a 
persecutory  tinge,  and  may  in  some  cases  be  attended 
with  auditory  hallucinations.  In  these  cases  there  is 
apt  to  be  the  same  lack  of  consecutiveness  and  some- 
times extravagance  in  the  delusions  that  are  observed 
in  the  exalted  ones,  but  this  is  not  always  the  case. 
The  hypochondriacal  fancies  have  an  extravagance  of 
character,  and  are  probably  based  to  some  extent  on 
perverted  and  misinterpreted  organic  sensations.  The 
patients  have  terrifying  delusions;  they  believe  they 
are  going  to  be  tortured,  hurt,  that  vermin  are  eating 
up  their  entrails,  etc.  This  agitated  type  of  depressed 
paretic  dementia  is  not  very  frequent,  but  it  sometimes 
is  met  with.  In  one  patient  observed  there  was  a  sort 
of  double  personality ;  he  very  frequently  spoke  of  him- 
self in  the  third  person,  but  if  it  were  suggested  that  this 
16 


242  GENERAL    PARESIS,    PARETIC    DEMENTIA. 

person  he  was  talking  of  must  be  dead,  he  would  most 
vehemently  deny  it,  and  finally  would  end  with  repeat- 
ing "  I  ain't  dead"  over  and  over  again. 

Another  feature  of  this  second  stage — and  this  is 
one  observed  most  frequently,  according  to  our  experi- 
ence, in  the  depressed  type — is  the  occurrence  of  sudden 
outbreaks  of  violence,  generally  of  short  duration. 
These  are  unusual,  but  they  are  not  infrequent,  and 
constitute  a  danger  in  this  class  of  cases.  In  some 
cases  these  attacks  are  quite  comparable  to  those  of 
the  epileptic  insane,  and  their  psychic  mechanism  is 
probably  similar  to  those. 

It  is  a  fact  perhaps  worth  mentioning  that  the  ex- 
travagant delusions  of  paretics  do  not  always  prevent 
their  appreciation  of  the  absurdity  of  similar  delusions 
in  others.  We  have  seen  a  paretic,  in  the  stage  of  full 
development  of  this  disease,  sitting  up  and  listening  to 
the  extravagancies  of  another  similar  unfortunate,  and 
repeating  to  himself  ' '  The  damned  liar ! ' '  whenever  the 
other's  nights  of  fancy  became  at  all  extreme.  His 
own  delusions  were  not  less  outrageous,  but  he  could 
still  appreciate  the  falsity  of  such  conceptions  in  others. 

With  the  aggravated  mental  symptoms,  the  bodily 
symptoms  become  more  pronounced.  The  muscular 
paresis  and  incoordination,  which  in  the  first  stage 
are  hardly  noticeable,  except  to  a  slight  degree 
in  the  muscles  of  expression  and  of  speech,  become 
decidedly  evident.  The  face  has  a  peculiar  expression- 
less smoothness  that  catches  the  eye  of  one  experienced 
with  these  cases  instantly  and  is  noticeable  to  one 
altogether  inexperienced.  The  speech  becomes  still 
thicker  and  more  characteristic,  the  voice  is  monoto- 
nous and  expressionless,  the  penmanship  soon  becomes 
shaky  and  more  or  less  illegible,  the  tremor  involves  the 
members  as  well  as  the  tongue  and  lips,  equilibration  is 
affected  so  that  stumbles  and  falls  are  liable  to  occur. 
The  muscular  power  is  not  lost,  but  is  weakened  and 


SYMPTOMS.  243 

its  control  is  defective ;  there  are  occasionally  contrac- 
tures. The  pupils  show  reflex  iridoplegia,  often  in- 
equality, myosis,  irregularity  of  outline,  and  later  in 
the  disease  marked  mydriasis.  Vasomotor  anomalies, 
flushings,  rise  of  temperature,  are  common.  The  ten- 
don reflexes  (knee,  ankle)  are  often  increased,  more 
rarely  lost;  the  superficial  reflexes  are,  in  our  experi- 
ence, less  commonly  exaggerated.  Fragility  of  bones  is 
sometimes  observed,  as  in  tabes,  and  the  breaking 
strain  of  the  ribs  is  sometimes  decidedly  decreased 
(Campbell,  Meyer). 

With  all  this  the  patient's  general  nutrition  may 
be  good,  and  it  is  rather  the  rule  for  them  to  take  on 
flesh  at  this  stage  of  the  disease.  The  appetite  is 
apt  to  be  excessive,  and  special  care  must  be  taken 
lest  through  haste,  and  probably  to  some  extent 
through  paresis  of  the  muscles  of  deglutition,  the 
patients  choke  when  eating.  Many  accidents  of  this 
sort  have  occurred  in  paretics,  and  it  is  a  good  practice 
to  have  their  food  cut  up  fine  to  prevent  their  occur- 
rence. Even  that  is  not  always  sufficient,  and  some 
observation  of  their  eating  is  always  advisable,  espe- 
cially in  this  stage  of  their  disorder. 

The  most  striking  phenomena  of  this  stage,  though 
they  may  occur  in  the  preceding,  are  the  apoplectiform 
and  epileptiform  attacks.  These  may  occur  many 
times.  It  is  not  uncommon  to  see  patients  temporarily 
hemiplegic  either  totally  or  partially,  and  it  is  the  rule 
for  nearly  all  traces  of  paralysis  to  disappear  in  a  day 
or  two,  or  even  in  a  few  hours,  leaving,  it  may  be,  a 
slightly  greater  degree  of  paresis,  however,  than  before 
the  attack.  The  convulsions  may  be  single,  and  fol- 
lowed sometimes  by  temporary  paralysis ;  or  there  may 
be  a  regular  status  epilepticus,  lasting  for  hours. 
We  have  counted  as  many  as  seventy-five  or  more  fits 
one  after  the  other,  and  after  all  had  ceased  the  patient 
was  hardly  appreciably  worse  than  before  the  attack. 


244  GENERAL    PARESIS,    PARETIC    DEMENTIA. 

The  final  stage  of  paretic  dementia  is  marked  by  an 
increase  of  both  mental  and  physical  symptoms,  but, 
as  in  the  case  of .  the  second  stage,  there  is  no  one 
phenomenon  that  characterizes  the  change,  unless  it  be 
the  general  and  pronounced  tendency  to  untidiness. 
This  is  due  in  some  cases  to  the  advancing  dementia, 
in  others  to  both  physical  and  mental  decadence.  In 
the  progress  of  the  disease,  the  paresis  attacks  the 
sphincters,  the  anesthesia  becomes  more  marked,  and 
the  patients  do  not  recognize  the  calls  of  nature.  Apart 
from  this  symptom  of  untidiness,  which  may  appear 
comparatively  early  in  some  cases,  there  are  others 
that  toward  the  close  of  the  paretic's  life  are  especially 
noticeable.  Such  are  the  grinding  of  the  teeth  from 
cerebral  irritation,  which  is  almost  incessant  in  some 
cases,  the  aggravated  paresis,  the  greater  frequency  of 
the  epileptiform  and  congestive  (apoplectiform)  at- 
tacks, the  circulatory  disturbances,  hematoma,  edema, 
asphyxia  or  gangrene  of  the  limbs,  and,  toward  the 
last,  the  bed-sores,  which  may  be  of  either  cerebral  or 
spinal  origin,  involving  either  the  buttocks  or  the  sacral 
region,  and  rapidly  progressing,  or  may  be  simply  the 
result  of  the  depraved  general  nutrition,  and  occur  at 
any  point  where  pressure  on  the  skin  occurs.  The 
mental  condition  in  this  final  stage  is  apt  to  be  that  of 
complete  dementia ;  the  patient  is  unable  to  help  him- 
self in  the  slightest  matter — to  dress,  or  even  sometimes 
to  eat.  Death  finally  closes  the  scene,  most  typically 
from  general  exhaustion  (marasmus) ,  or  in  a  convulsive 
or  congestive  attack. 

The  average  duration  of  paresis  from  its  incipiency 
to  its  finale  has  been  estimated  as  about  three  years, 
but  there  are  wide  variations  in  individual  cases.  The 
shortest  duration  we  have  observed  was  under  two 
months  from  the  first  observation  of  anything  wrong 
to  the  death  that  occurred  in  convulsions.  It  is  prob- 
able, however,  that  in  this  instance  there  were  dis- 


SYMPTOMS.  245 

turbances  that  were  not  objectively  noted  for  some 
time  prior  to  the  patient's  breakdown.  The  longest 
case  continuously  observed  was  something  over  seven 
years,  in  more  than  five  of  which  the  case  was  almost 
or  quite  stationary;  a  very  well-marked  case  of  mild 
exalted  delusional  insanity  with  hallucinations  and 
paretic  speech,  but  otherwise  no  very  visible  paretic 
symptoms.  This  case  was  remarkable  for  the  long 
continuance  of  the  second  stage.  After  some  five 
years  or  more  of  this,  it  passed  into  the  final  stage 
rather  abruptly,  and  the  mental  and  physical  decadence 
was  typical  and  progressive.  It  is  not  uncommon  to 
see  remissions,  more  or  less  emphatic,  in  this  disorder, 
and  these  may  last  for  years.  Some  cases  of  paresis 
have  been  reported  as  lasting  over  ten  years  altogether, 
including  remissions.  Long  remissions  are  claimed  by 
some  authors  (Mendel,  Bremer)  to  be  more  frequent  of 
late  than  formerly. 

The  question  whether  recovery  can  take  place  in 
paresis  is  by  no  means  a  settled  one.  Certain  authors 
within  the  last  ten  years  have  reported  cases  con- 
sidered by  them  as  recovered,  but  the  possibility  of 
lengthy  remissions  should  not  be  overlooked,  and  this 
rather  obscures  the  question.  Most  authorities  do  not 
recognize  the  recovery  as  a  rare  termination  in  fully 
developed  paresis,  and  while  it  may  be  admitted  as 
perhaps  possible,  the  chances  are  too  poor  to  enable  us 
to  count  upon  it  even  in  exceptional  cases. 

The  typical  modes  of  death  have  been  already  alluded 
to,  but  it  may  occur  in  many  other  ways.  Death  from 
suffocation  from  food  is  a  constant  peril  in  advanced 
cases,  and  they  may  also  choke  from  swallowing  other 
substances.  We  have  known  a  paretic  to  fatally  choke 
himself  with  his  own  feces.  Aspiration  pneumonia  is 
another  danger,  particles  of  food  or  drink  passing  down 
into  the  air-passages.  Intercurrent  lung  or  renal  dis- 
eases are  not  uncommon  causes  of  death ;  heart  failure 


246  GENERAL    PARESIS,    PARETIC    DEMENTIA. 

and  blood-poisoning  from  septic  absorption  from  ab- 
scesses or  sores  are  other  possibilities.  Accidents  are 
liable  to  occur, — falls,  bruises,  etc., — and  these  may 
also  be  fatal. 

The  pathology  of  paresis  has  been  very  extensively 
studied.  The  macroscopic  changes  are  very  well 
marked  and  extensive,  and  are  those  of  a  diffused 
meningoencephalitis,  especially  of  the  convexity  of 
the  hemispheres.  The  dura  in  a  large  majority  of 
cases  presents  adhesions  to  the  calvarium,  especially 
in  the  vicinity  of  the  median  longitudinal  fissure, 
and  in  the  Rolandic  and  frontal  regions,  though  the 
adhesions  are  not  by  any  means  confined  to  these  parts, 
and  may  exist  anywhere.  The  pia  arachnoid  is  thick- 
ened and  vascular ;  in  old  cases  opaque  and  milky ;  the 
veins  enlarged ;  in  places  it  has  a  bright  red  inflamma- 
tory flush ;  the  Pacchionian  granulations  are  apt  to  be 
abnormally  increased.  Adhesions  exist  between  the 
pia  and  dura,  and  between  the  pia  and  cortical  sub- 
stance, so  that  in  removing  the  membrane,  the  latter 
comes  away  in  patches,  leaving  marked  erosions,  which 
are  generally  most  frequent  in  the  anterior  region, 
though  they  may  occur  anywhere  over  the  brain  sur- 
face. In  advanced  cases  the  convolutions  are  wasted 
and  the  brain  generally  somewhat  atrophied.  The 
ventricles  may  be  dilated,  and  sometimes  one  or  both 
may  present  a  dark  slaty  color  on  their  surfaces. 

In  the  basal  ganglia  there  may  be  macroscopic 
changes,  cavities,  capillary  hemorrhages,  etc. 

The  microscopic  changes  consist  in  alterations  of  the 
vessels,  thickening  and  induration  of  their  walls,  so 
that  sometimes  we  have  felt  the  minute  capillaries  as 
bristling  points  on  passing  the  finger  over  a  fresh-cut 
section  of  the  brain.  It  has  seemed  possible  to  us  that 
all  the  morbid  changes  start  in  the  vessels,  the  degenera- 
tion of  the  nerve  elements  and  neuroglia  proliferation 
being  secondary  processes.     The  close  relation,  how- 


DIAGNOSIS.  247 

ever,  of  tabes  with  paresis,  and  the  accepted  nervous 
pathology  of  the  former,  suggest  strongly  a  primary 
involvement  of  the  nerve  elements  in  the  latter  disease. 
The  microscope  shows  changes  occurring  in  the  vessels 
and  in  the  nerves  very  easily  in  the  disease,  and  it  is 
not  always  possible  to  say  which  antedates  the  other. 
In  either  case  we  can  reasonably  assume  that  a  toxin 
carried  through  the  tissues  by  the  circulation  is  the 
primary  cause  both  of  the  vascular  and  the  neurotic 
lesions.  The  latter  are  constant.  Occasionally  with 
the  typical  paralytic  symptoms  gummata  are  found, 
especially  in  the  vicinity  of  the  basal  vessels. 

Mott,  one  of  the  latest  contributors  to  the  pathology 
of  paresis,  considers  the  primary  changes  to  occur  in 
the  neuron,  which,  weakened  by  toxins,  gives  way 
under  conditions  of  stress.  With  their  wasting  other 
toxic  products  (cholin,  etc.)  are  given  off,  and  these 
again  react  on  the  nerve  elements  through  the  lymph- 
atics and  the  blood  and  set  up  inflammatory  conditions 
in  the  vessels  and  cortex,  producing  the  symptoms  of 
the  disease. 

The  spinal  cord  may  also  be  involved  in  the  menin- 
geal disease,  and  there  may  be  also  degenerative 
changes  in  the  posterior  or  lateral  columns,  or  in  both, 
and  also  in  the  peripheral  nerves.  The  viscera  may 
also  show  the  lesion  of  tubercular  or  other  disease ;  the 
kidneys,  heart,  and  liver  are  often  found  involved  in 
some  degenerative  processes,  and  numerous  vascular 
degenerations  appear  elsewhere. 

Diagnosis. — Much  has  been  said  as  to  the  importance 
of  the  early  diagnosis  of  paresis,  but  practically  there 
is  no  possibility  of  a  positive  diagnosis  in  its  earliest 
stages,  except  in  those  cases  which  come  on  suddenly, 
with  the  characteristic  bodily  symptoms  among  the 
first  to  appear.  As  stated  already,  such  cases  occur, 
though  they  are  rather  unusual.  In  a  much  larger 
proportion  the  earliest  symptoms  are  indistinguishable 


248  GENERAL    PARESIS,    PARETIC    DEMENTIA. 

from  those  of  neurasthenia,  and  any  differential  dis- 
tinction between  the  conditions  is  impossible  at  this 
stage.  It  is  only  after  the  speech  becomes  affected 
and  other  paretic  and  mental  signs  develop  that  the 
diagnosis  becomes  certain.  The  physical  symptoms 
may  and  often  do  appear  before  the  mental  impairment 
is  pronounced,  the  latter  being  a  later  phenomenon,  and 
cases  may  occur  where  this  does  not  appear  at  all  during 
the  course  of  the  disorder,  the  patient  succumbing 
early  to  convulsive  or  apoplectic  seizures.  The  posi- 
tive diagnosis  of  paresis  may  be  said  to  depend  upon 
the  physical  features  of  the  disorder;  they  may  be 
slight  and  easily  unrecognized  by  inexperienced  indi- 
viduals, but  their  existence  is  usually  quickly  noted 
by  the  skilled  observer,  who  is  then  able  to  name 
the  disorder.  Only  one  or  two  common  or  com- 
paratively common  forms  of  mental  derangement 
closely  simulate  paresis  in  these  respects;  these  are 
alcoholism  and  plumbic  insanity.  In  the  former  a 
pseudo-paretic  dementia  is  not  so  rare,  the  paresis,  the 
speech  impairment,  the  pupillary  symptoms,  as  well  as 
the  characteristic  psychic  symptoms,  may  all  be  pres- 
ent, and  give  rise  to  an  erroneous  diagnosis.  There 
are,  however,  certain  marks  that  serve  somewhat  to 
distinguish  this  form  from  the  general  disease,  and 
these  are  the  direct  connection  with  alcoholic  derange- 
ment, the  suddenness  of  the  onset,  and,  more  than 
anything  else,  the  equally  rapid  disappearance  of  the 
symptoms  under  proper  treatment.  It  must  be  added 
here  that  there  do  occasionally  occur  cases  of  alcoholic 
paresis  of  a  certain  type  that  are  not  curable  and  are 
progressive,  but  these  are  not  so  likely  to  be  confounded 
with  genuine  paresis.  Plumbism  is  also  said  to  cause 
a  condition  closely  resembling  paresis,  but  also  often 
curable.  It  is  said  by  Regis  to  commence  abruptly, 
like  alcoholic  pseudo-paresis,  and  to  differ  from  the 
genuine    form    in    other    respects — the    less    frequent 


DIAGNOSIS.  249 

pupillary  disorders,  the  tremor  is  more  intermittent 
and  spasmodic,  the  dementia  is  more  apparent  than 
real.  The  disorder  is  accompanied  with  the  plumbic 
blue  line  on  the  gums,  and  other  symptoms  of  saturn- 
ism, and  is  liable  to  recur  under  the  influence  of  the 
same  causes. 

It  is  well  known  that  the  typical  symptoms  of  paresis 
may  accompany  comparatively  recent  syphilitic  brain 
disease,  and  these  cases  have  been  used  as  a  last  resort 
by  the  advocates  of  the  existence  of  a  specific  pseudo- 
paresis,  largely  on  the  claim  that  they  are  amenable  to 
specific  treatment.  So  far  as  our  observation  has  ex- 
tended, this  is  not  generally  the  case;  such  instances 
have  been  usually  as  rebellious  to  treatment  as  any 
form  of  the  disorder  occurring  many  years  after  the 
last  manifestations  of  luetic  infection.  We  are  there- 
fore inclined  to  include  these  amongst  the  true  paretics, 
from  which  they  are  clinically  indistinguishable. 

Still  another  condition  that  may  give  rise  to  errors  in 
diagnosis  is  that  of  atheromatous  disease  of  the  vessels 
of  the  brain,  which  may  cause  symptoms  resembling 
paresis  in  many  respects.  Cases  of  paresis  reported 
over  fifty-five  or  sixty  years  of  age  are  open  to  suspi- 
cion, and  should  be  carefully  studied  as  to  the  proba- 
bility of  their  being  only  peculiar  forms  of  organic 
senile  brain  disorder.  Other  organic  brain  disease  than 
senile  atheroma  may  also  give  rise  to  symptoms  of 
paresis;  arteriosclerosis  from  any  cause,  disseminated 
sclerosis,  and  even  brain  tumor,  as  admitted  by  Krae- 
pelin,  may  lead  to  a  false  diagnosis  in 'special  instances ; 
but  careful  observation  of  all  the  symptoms  will  gener- 
ally clear  the  case  in  time,  and  leave  no  doubt  as  to  its 
real  nature. 

Some  episodic  conditions  of  paresis  may  easily  be 
confounded  at  first  sight  with  other  forms  of  insanity: 
the  depression  in  the  early  stages  may  suggest  melan- 
cholia ;  maniacal  attacks  occurring  early  may  similarly 


250  GENERAL    PARESIS,    PARETIC    DEMENTIA. 

cause  error ;  the  hypochondriacal  phase  of  early  paresis 
is  especially  liable  to  be  wrongly  diagnosed,  and  there 
is  not  invariably,  as  Peterson  claims,  a  special  paretic 
character  to  the  delusions.  Paresis  may  overlie  any 
of  the  degenerative  conditions,  and  such  complications 
embarrass  the  diagnosis ;  or  combination  with  paranoia 
or  circular  insanity  is  not  altogether  infrequent.  The 
syndrome  of  catatonia  may,  as  Worcester  has  recently 
shown,  occur  in  paretics,  and  acute  confusional  delirium 
is,  as  already  mentioned,  a  possible  form  of  its  terminal 
stage.  It  is  often  well  to  reserve  an  opinion  in  dubious 
cases  till  time  and  careful  study  have  justified  a  positive 
diagnosis. 

When  paresis  occurs  in  the  young  it  may  possibly 
simulate  idiocy,  as  suggested  by  McDonald,  and  we 
believe  also  by  some  French  authorities  quite  recently. 
Homen  has  published  cases  of  congenital  syphilis  in  the 
young,  affecting  several  members  of  one  family,  that 
had  some  resemblance  in  their  symptoms  to  paresis, 
and  such  cases  may  create  confusion  now  that  the 
possibility  of  juvenile  paresis  is  recognized. 

Prognosis. — This  may  be  set  down  as  pretty  uni- 
formly unfavorable.  Cases  of  cure  have  been  reported, 
but  the  possibility  of  lengthy  remissions  of  the  disease 
should  be  borne  in  mind  in  estimating  apparent  cures. 

Treatment. — As  paretic  dementia  is  practically  a 
hopeless  disease,  at  least  when  it  has  become  fairly 
established,  curative  treatment  is  generally  out  of  the 
question,  and  the  most  that  we  can  encourage  ourselves 
to  hope  for  is  to  alleviate  symptoms,  encourage  the 
occurrence  of  remissions,  and  delay  the  progress  so  far 
as  possible  of  the  affection.  It  is  sometimes  said  that 
early  treatment  may  be  effective,  but  for  reasons 
already  stated  the  recognition  of  the  disorder  in  its 
early  stages  is  rarely  possible,  if,  indeed,  it  is  ever  so. 
The  damage  to  the  brain  is  already  advanced,  as  a  rule, 
before  the  diagnosis  can  be  made. 


TREATMENT.  25 1 

With  the  almost  universal  antecedent  of  syphilis,  it 
might  naturally  be  supposed  that  a  trial  of  specific 
medication  would  be  in  order,  at  least  in  the  cases 
where  the  specific  disease  is  of  comparatively  recent 
date.  Some  authorities  mention  this  only  to  condemn 
it,  but  there  are  many  cases  in  which,  according  to 
our  experience,  a  cautious  trial  of  specific  medication 
with  iodids  may  do  no  harm,  and  there  are  some  in 
which  it  has  seemed  to  be  of  some  benefit.  If  it  is 
employed,  it  ought  to  be  carefully  watched,  and 
stopped  if  it  shows  the  least  sign  of  disagreeing  with 
the  patient's  general  health,  or  causing  any  aggrava- 
tion of  the  paretic  symptoms.  Not  very  much  is  to 
be  expected  from  its  use  in  any  event,  even  in  those 
cases  in  which  tertiary  symptoms  are  still  apparent. 
Considerable  benefit  has  been  claimed  in  times  past 
from  active  counterirritation,  even  blistering  the  scalp 
to  the  extent  of  denuding  and  corroding  the  skull,  but 
such  measures  are  little  used  at  the  present  time. 
Very  recently  Dr.  G.  W.  Foster  has  reported  a  remark- 
able success  with  hydrotherapy  in  paresis;  in  six  out 
of  twenty-one  cases  thus  treated  a  complete  arrest  of 
the  disease  was  obtained  for  periods  ranging  from  some 
months  to  three  years  and  over.  From  his  testimony 
the  results  of  this  treatment  are  the  most  encouraging 
of  any  that  have  been  tried,  and  full  details,  as  yet  un- 
published, are  to  be  desired.  Hydrotherapy  in  other 
hands  has  not  always  been  so  successful.  The  pro- 
longed warm  bath  for  half  an  hour  to  an  hour,  with 
perhaps  cold  applications  to  the  head,  is  useful  some- 
times in  the  excited  stage  in  cases  not  too  far  ad- 
vanced, but  shower-baths,  cold  baths,  etc.,  are  in  our 
experience  generally  contraindicated. 

The  paretic  in  the  active  progressive  stages  of  his 
disease  is  always  best  treated  in  an  asylum  or  its 
equivalent.  During  the  remissions  it  may  be  possible 
for  him  to  be  released  temporarily,  but  he  should  al- 


252  GENERAL    PARESIS,    PARETIC    DEMENTIA. 

ways  be  under  medical  oversight.  The  excitement  of 
outside  life,  the  lack  of  regulation  of  habits,  and,  it  may 
be,  renewal  of  excesses,  are  all  likely  to  bring  on  a 
relapse,  and  render  paroling  or  furloughing  this  class 
of  patients  somewhat  of  a  perilous  experiment. 

The  symptoms  that  may  occur  from  time  to  time  of 
excitement,  etc.,  call  for  appropriate  treatment — seda- 
tives, hypnotics,  etc.  In  the  congestive  attack  it  may 
occasionally  be  useful  to  employ  brisk  purgatives  and 
local  applications  to  relieve  the  congestion,  but  abstrac- 
tion of  blood  is  undesirable.  The  condition  of  the 
bowels  is  always  to  be  watched ;  any  constipated  state 
is  likely  to  aggravate  the  disorder,  and,  on  the  other 
hand,  paretics  are  occasionally  carried  off  suddenly  by 
choleraic-appearing  diarrhea  attacks.  In  the  advanced 
stages  when  the  patient  is  bedridden  and  untidy,  con- 
stant care  should  be  exercised  to  prevent  bed-sores, 
which  will  sometimes,  however,  occur  in  spite  of  the 
most  careful  treatment.  Occasionally  they  seem  to 
be  directly  connected  with  cerebral  or  spinal  lesions, 
and  form  rapidly  appearing  and  extensive  sloughs  over 
the  sacrum  or  the  buttocks,  but  the  more  common 
form  is  that  due  to  the  general  deteriorated  trophic 
functions,  occurring  at  any  point  subjected  to  pressure.. 
Whichever  way  they  occur,  they  form  a  troublesome 
complication,  and  one  that  helps  materially  to  the  final 
fatal  termination.  The  utmost  cleanliness,  bathing 
with  diluted  alcohol,  frequent  changes  of  position, 
water  or  air  cushions  or  mattresses,  are  at  best  only 
palliative  measures  in  these  cases.  Attention  should 
be  paid  also  in  paretic  cases  to  the  slightest  suppurative 
inflammation,  as  a  general  pyemia  or  septicemia  is 
often  easily  set  up.  On  the  other  hand,  in  the  second 
stage  there  is  frequently  observed  an  especially  marked 
readiness  of  repair  of  injuries,  but  this  is  rarely,  if  ever, 
the  case  in  the  final  stages  of  the  disorder. 

In  closing  the  subject  of  paresis,  we  may  recapitu- 


TREATMENT.  253 

late,  at  the  risk  of  some  repetition,  the  varieties  that 
have  been  remarked  in  its  symptoms  and  progress. 
The  typical  form  with  excitement  and  exalted  delu- 
sions has  been  sufficiently  described;  so  also  the  de- 
pressed and  hypochondriacal  form.  The  latter  occurs, 
according  to  Kraepelin's  estimate,  in  about  27%  of 
all  cases;  we  should  estimate  it  at  rather  a  less  figure 
in  our  experience.  If,  however,  the  typical  demented 
type  is  here  included,  a  considerably  higher  percentage 
may  be  allowed.  In  this  the  dementia  predominates, 
and  the  delusions  and  other  active  intellectual  aberra- 
tions may  be  altogether  absent.  According  to  a  recent 
writer  (Bremer),  this  type  is  becoming  more  and  more 
frequent  of  late  years,  and  tends  to  replace  the  typical 
form.  There  are  occasionally  occurring  cases  in  which 
the  mental  symptoms  of  the  early  stages  are  wanting, 
and  the  dementia  comes  on  at  once  after  an  apoplectic 
or  convulsive  attack.  There  are  also  cases  of  paresis 
without  these  attacks  of  either  kind,  and  others  in 
which  they  are  so  frequent  as  to  dominate  the  syn- 
drome, and  mental  or  emotional  symptoms  are  almost 
completely  lacking  during  the  entire  course,  or  so 
slight  as  to  readily  pass  unnoticed.  In  other  cases 
still,  the  earliest  symptoms  are  spinal,  and  the  disorder 
may  be  diagnosed  as  tabes,  till  these  disappear  and 
give  place  to  the  more  typical  physical  symptoms  of 
paresis.  Cases  like  this  are  rather  rare,  but  we  have 
observed  several  such.  In  other  cases  the  ataxic  symp- 
toms continue,  though  more  or  less  masked  by  the 
advancing  paresis.  Still  another  form  may  appear 
quickly,  and  take  on  the  symptoms  of  acute  delirium, 
carrying  the  patient  off  in  a  few  days  or  weeks — the 
so-called  galloping  paresis.  Then  we  may  mention  the 
juvenile  paresis,  appearing  generally  at  or  near  puberty 
in  victims  of  hereditary  syphilis.  In  these  the  symp- 
toms may  be  more  or  less  typical,  but  generally  of  the 
demented   rather   than   the   active   or   exalted   type. 


254  GENERAL    PARESIS,    PARETIC    DEMENTIA. 

Lastly,  we  have  the  circular  type,  in  which  the  form  of 
the  peculiar  degenerative  cyclic  insanity  is  superim- 
posed on  the  paresis. 

The  percentages  of  the  different  forms  are  thus  given 
by  Kraepelin:  The  agitated  form,  11%;  the  demented, 
40%;  the  expansive  type,  15  to  16%;  the  depressive 
type,  27%.  The  other  types  are  exceptional.  In  our 
experience  we  should  give  certainly  a  larger  percentage 
of  the  expansive  type  as  existing  among  paretics  a  few 
years  ago,  and  a  very  much  smaller  one  for  the  depres- 
sive type. 

It  must  be  remembered  that  the  symptoms  and  the 
character  of  the  delusions  are  largely  influenced  by  the 
natural  bent  of  the  patient,  and  this  is  also  true  to  a 
large  extent  with  the  type  of  the  disease.  Depressed 
forms  of  mental  disorder  seem  to  increase  with  civiliza- 
tion, and  paresis  falls  probably  in  this  into  the  general 
order  of  things. 

Another  notable  fact  is  the  increase  of  paresis  in 
women,  which  is  more  marked  in  Europe  than  in  this 
country.  Here  the  ratio  is  still  near  the  old  mark — 
one  woman  to  five  or  six  male  paretics ;  but  the  number 
of  the  former  is  appreciably  increasing  here  also.  It 
has  been  often  observed  that  this  increase  abroad  is 
chiefly  amongst  the  lower  classes,  and  in  the  large 
cities,  and  that  a  well-to-do  female  paretic  is  a  rarity. 
In  this  country  this  is  also  true,  to  a  certain  extent,  but 
women  in  good  or  fair  condition  in  life,  and  of  good 
education,  furnish  an  appreciable  proportion,  and  the 
disorder  cannot  be  said  to  be  exactly  rare  or  excep- 
tional amongst  them. 


CHAPTER  XIV. 

ORGANIC  INSANITY. 

Organic  dementia,  as  it  is  understood  in  our  classi- 
fication, includes  those  conditions  of  mental  impair- 
ment without  active  insane  delusions  or  active  symp- 
toms of  either  depression  or  exaltation,  following  gross 
lesions  or  disease  of  the  brain,  and  including  also  a 
certain  class  of  cases  occurring  in  advanced  life  where 
many  of  the  symptoms  strongly  suggest  paretic 
dementia  as  it  occurs  in  younger  individuals.  We 
include  these  because  this  appears  to  be  the  best  place 
for  them,  and  because  they  are  etiologically  distinct, 
in  our  opinion,  from  true  cases  of  paresis.  The  usual 
effects  of  brain  lesions  beyond  the  merely  temporary 
ones  are  a  certain  degree  of  mental  enfeeblement  or 
impairment,  though  in  many  cases  this  is  so  slight  as 
to  practically  be  a  negligible  quantity.  An  ordinary 
apoplectic  attack  may  be  recovered  from  so  completely 
that  no  trace  is  apparent  of  its  effect  upon  the  mind. 
This  is  especially  true  of  many  cases  of  hemorrhages  or 
embolism  in  the  basal  portion  of  the  brain,  involving 
simply  the  functions  of  some  of  the  motor  tracts. 
Repeated  attacks,  however,  of  this  kind  are  apt  to 
show  their  effects,  and  very  extensive  lesions  may  be 
serious  in  the  mental  involvement  produced  from  the 
very  first.  Lesions  in  other  portions  of  the  brain  affect 
the  mind  according  to  the  organs  or  regions  involved, 
and  also  in  accordance  with  their  extent.  The  mind 
may  be  a  blank  at  once  from  the  time  of  the  injury,  as 
in  cases  where  a  cerebral  traumatism  has  completely 
destroyed  memory  and  consciousness  of  the  past  life, 
which  are  subsequently  restored  by  the  trephining  out 

255 


256  ORGANIC    INSANITY. 

of  the  depressed  portion  of  the  bone,  etc.  Many  of 
these  cases  are  apocryphal,  especially  as  regards  the 
reported  sudden  cures  after  a  lapse  of  several  years, 
but  it  is  altogether  possible  for  the  mental  faculties  to 
be  completely  and  permanently  obtunded  by  any 
lesion  of  sufficient  extent  and  involving  the  higher 
centers  indispensable  to  the  action  of  the  mind. 

The  symptoms  following  brain  lesion  vary  from 
slight  impairment,  as  already  stated,  to  the  condition 
just  described,  and  not  infrequently  epilepsy  with 
consequent  dementia  is  a  sequel.  The  cases  here  con- 
sidered are,  however,  those  of  dementia  in  its  various 
degrees,  and  loss  of  memory,  of  power  of  orientation, 
and  of  the  higher  inhibition  are  the  most  notable  of  the 
special  symptoms.  The  subject  may  have  lost  all 
knowledge  of  events  immediately  after  the  lesion, 
while  he  may  be  able  to  talk  and  reason  correctly  as  to 
matters  immediately  at  hand.  The  impairment  may 
be  such  that  he  may  lose  himself  within  a  few  steps 
from  his  own  door,  may  neglect  the  ordinary  decencies 
of  social  life,  and  in  some  cases  may  be  unable  even  to 
attend  to  his  own  slightest  wants.  These  patients  are 
not  usually  dangerous  except  to  themselves,  and  in 
that  respect  only  through  their  helplessness  and  their 
inability  to  reason.  Nevertheless,  there  may  be 
suicidal  tendencies,  and  from  lack  of  self-control  even 
homicides  may  occur ;  these,  however,  are  so  rare  that 
they  are  not  usually  considered  in  describing  this 
special  form  of  insanity.  One  of  the  commonest  types 
of  organic  dementia  is  that  associated  with  the  athero- 
matous arteries  of  old  age,  or,  it  may  be,  of  premature 
senility.  In  some  of  these  cases  we  have  what  has  been 
already  mentioned,  a  condition  quite  closely  resembling 
paresis  with  its  thickened  speech,  its  unsystematized 
delusive  ideas,  and  general  physical  weakness.  In  our 
opinion  the  cases  of  paresis  that  have  been  reported 
in  individuals  over  sixty  years  of  age  are  generally -of 


TREATMENT.  257 

this  type,  and  may  or  may  not  have  been  preceded  by 
earlier  specific  disease.  It  is  rare  to  see  a  typical 
paretic  pass  the  age  of  fifty,  and  we  doubt  if  paresis 
ever  occurs  after  sixty.  The  differences  are  not  so  very 
striking  to  the  ordinary  observer,  but  in  these  aged 
cases  there  is  a  lack  of  the  active  delusional  type  that 
we  see  in  the  majority  of  those  in  middle  or  early  life, 
and  the  general  facies  of  the  disease  has  a  character- 
istic difference  which  is  hard  to  describe,  but  never- 
theless exists.  If  we  were  asked  to  be  specific  in  regard 
to  this,  we  could  only  say  that  there  is  a  special  senile 
character,  and  in  the  most  of  these  cases  we  do  not  find 
the  early  antecedents  of  true  paresis.  There  are  also 
the  various  physical  signs  of  senile  arterial  disease,  the 
senile  heart,  the  tortuous  vessels,  and  the  general 
symptoms  of  pathologic  senile  decay. 

Syphilitic  disease  may  produce  an  organic  dementia 
with  symptoms  characteristic  of  the  probable  lesions 
that  have  occurred  within  the  brain,  such  as  syphilitic 
growths,  syphilitic  arteries  with  hemorrhages,  etc. 

There  is  no  special  characteristic  sign  which  we  can 
name  of  the  dementia  from  hemorrhage,  embolism, 
thrombosis,  tumor,  or  traumatism,  and  the  diagnosis 
of  these  conditions  must  be  made  by  the  history  of 
the  case  and  the  special  local  and  other  symptoms  in 
the  motor  and  sensory  spheres. 

The  treatment  of  organic  insanity  will  vary  according 
to  the  cause,  and  it  is  only  in  a  few  cases,  where  the 
injury  is  comparatively  slight,  or  in  some  recent  cases, 
and  in  cases  where  specific  disease  is  known  or  suspected 
to  exist,  that  the  prognosis  is  hopeful.  In  the  great 
majority  of  cases,  and  especially  in  those  occurring  in 
advanced  life,  the  chances  of  improvement  or  recovery 
are  practically  nil.  There  are  many  patients  of  this 
class  sent  to  asylums.  They  are  easily  cared  for, 
though  sometimes  troublesome,  and  what  has  to  be 
done  for  them  is  to  make  life  as  comfortable  as  possible, 
17 


250  ORGANIC    INSANITY. 

give  them  such  liberties  and  privileges  as  are  possible, 
insure  their  cleanliness  and  proper  nutrition,  and 
protect  them  from  the  dangers  to  which  they  are 
liable  from  their  weakness,  lack  of  self-control,  and 
their  inability  to  care  for  themselves. 

Many  cases  of  so-called  senile  insanity  are  really  of 
this  type,  and  many  cases  of  organic  brain  lesions,  with 
mental  disorder,  have  to  be  classed  with  other  forms 
of  mental  disease.  A  large  proportion  of  the  epileptic 
insanity  is  truly  organic  dementia.  The  same  is  the 
case  with  some  forms  of  delusional  insanity  which 
follow  injuries,  and  especially  those  cases  that  are  due 
to  insolation,  which  often  causes  a  peculiar  type  of 
delusional  paranoia  without  marked  dementia.  The 
cases  here  included  are  only  those  in  which  dementia 
is  the  leading  feature,  and  directly  traceable  to  the 
cerebral  lesions,  and  also  often  associated  with  the 
physical  symptoms  due  to  the  lesion. 


CHAPTER  XV. 
INSANITIES  OF  THE  NEUROSES. 

The  insanities  of  this  group  are  peculiar  in  being 
associated  with  special  forms  of  nervous  disease  or  with 
special  symptoms,  which  themselves  are  not  ranked 
among  the  mental  derangements.  It  is  not  in  our  plan  to 
discuss  these  disorders  or  symptoms,  but  only  to  describe 
concisely  the  psychic  derangements  sometimes  asso- 
ciated with  them .  Epilepsy ,  hysteria ,  etc . ,  so  far  as  they 
are  not  directly  associated  with  insanity,  their  symp- 
toms, treatment,  etc. ,  are  not  considered,  and  this  mater- 
ially lessens  the  compass  of  our  subject.  Hysteria,  it  is 
true,  is  itself  in  a  certain  sense  a  mental  disorder,  but  in 
its  ordinary  manifestations  the  mental  symptoms  are 
not  usually  considered  as  insanity,  hence  these  will  not 
be  considered  here.  It  is  only  when  the  mental  changes 
become  so  decided  that  they  pass  well  beyond  the 
borderland  region  that  they  are  properly  called  hysteric 
insanity;  so  in  epilepsy  the  convulsions  and  the  tem- 
porary mental  obfuscation  and  all  the  manifold  other 
peculiarities  may  occur  and  yet  the  subject  not  be 
fairly  called  insane.  For  the  discussion  of  these  the 
reader  is  referred  to  works  especially  on  nervous  dis- 
orders ;  they  do  not  form  part  of  our  subject  here  dis- 
cussed. 

While  these  neuroses  are  largely  degenerative,  and 
their  associated  mental  disorders  are  therefore  to  a 
great  extent  based  on  an  originally  defective  and 
degenerate  constitution,  this  is  not  always  the  case; 
the  neuroses  as  well  as  the  insanity  may  be  acquired 
through  disease,  trauma,  or  otherwise.     It  has  seemed 

259 


260  INSANITIES    OF    THE    NEUROSES. 

best  to  us  therefore  to  treat  of  them  here  rather  than 
in  connection  with  the  degenerative  insanities. 

EPILEPTIC  INSANITY. 

Epileptic  insanity  includes  all  the  mental  disorders 
directly  associated  and  connected  with  the  epileptic 
neurosis.  It  thus  includes  a  wide  range  of  clinical 
symptoms,  but  in  all  cases  they  are  more  or  less  tinged 
with  the  special  character  stamped  upon  them  by  the 
brain  disorder.  The  proportion  of  epileptics  who  are 
insane  is  not  so  great  as  is  sometimes  estimated,  though 
some  have  gone  so  far  as  to  consider  all  epileptics  as  to 
some  degree  mentally  affected  or  abnormal.  The  fact 
that  some  of  the  world's  greatest  names  are  those  of 
epileptics  would  not  of  itself  disprove  this,  but  the  other 
fact,  that  every  physician  and,  indeed,  nearly  every 
one  knows,  of  average  individuals  who  have  suffered 
from  the  disorder  or  symptoms  of  epilepsy,  is  a  stronger 
proof  of  its  incorrectness.  Probably  one-half  of  the 
epileptics  sooner  or  later  suffer  some  marked  mental 
deterioration  if  they  survive  long  enough,  and  in  half 
of  these  the  change  may  go  far  enough  to  make  them 
proper  subjects  to  be  called  insane.  In  the  other  half 
the  mental  deterioration  is  not  marked,  though  the 
victims  are  in  a  large  majority  of  the  cases  seriously 
handicapped  by  their  disease.  In  a  very  considerable 
proportion  of  cases  the  epilepsy  is  of  rare  occurrence, 
and  in  some  it  is  merely  an  episode  of  a  certain  period 
of  special  stress,  and  is  completely  recovered  from  as 
far  as  future  attacks  are  concerned.  The  great  mass  of 
average  epileptics  are  hardly,  properly  speaking,  in- 
sane. Many  of  them  are  mentally  weak  in  certain 
directions;  many  are  almost  normal;  and  a  few  suffer 
really  no  evil  effects,  so  far  as  their  mental  constitution 
is  concerned,  from  their  rare  and  episodic  attacks. 

Epileptic  weak-mindedness,  which  may  be  called  the 
first  degree  of  epileptic  insanity,  is  characterized  by 


EPILEPTIC    INSANITY.  261 

certain  noticeable  limitations  rather  than  aberrations. 
The  patients  lack  initiative ;  they  are  restricted  in  their 
ideas  and  tedious  in  their  expression  of  them.  Memory- 
is  unimpaired;  intellection,  within  the  limits  of  the 
patients'  capacity,  is  fair;  they  appear  to  have  no  dis- 
turbances of  consciousness  whatever  in  the  intervals 
between  their  fits.  With  this,  however,  there  is  often, 
and  one  may  say  generally,  an  irritability  of  disposition 
and  a  certain  loss  of  self-control,  showing  itself  in 
attacks  of  temper  or  an  unpleasant  peevish  disposition. 
It  is  often  said  that  the  first  signs  of  mental  disorder  in 
epileptics  are  seen  in  a  change  of  character,  and  a 
special  type  of  perverted  emotionalism  and  disposition 
has  been  described  as  characteristic.  According  to 
this  view,  epileptics  are  generally  in  this  stage  either 
vicious  and  violent  or  cajoling  and  treacherous;  in 
either  case  liable  to  violent  explosions  of  temper  and 
unreliable.  This  is  true  only  to  a  certain  extent ;  there 
are  many  epileptics  who  are  of  these  types,  and  there 
are  more,  in  our  opinion,  who  are  not.  Even  the  char- 
acteristic irritability  is  not  by  any  means  universal; 
there  are  many  mentally  affected  epileptics  who  are 
actually  insane  at  times,  whose  disposition  and  char- 
acter are  excellent,  and  the  general  charges  made 
against  them  as  a  class  do  not  do  them  justice. 

In  many  more  abnormal  cases  the  weak-mindedness 
passes  into  decided  dementia  of'  the  stupid  order, 
memory,  general  intelligence,  going  together  by  the 
board,  till  in  the  final  stages  the  patient  simply  lives 
a  sort  of  vegetative  existence,  unable  to  even  care  for 
himself  in  the  slightest  matters.  This,  however,  is  not 
characteristic  epileptic  insanity ;  it  is  simply  an  organic 
dementia  of  epileptic  origin,  of  which  it  retains  no 
special  trace,  except  perhaps  a  still-retained  peculiar 
irritability  and  the  recurring  convulsions. 

The  characteristic  insanity  of  epilepsy  is  that  di- 
rectly connected  with  the  attacks  and  coloring  to  a 


262  INSANITIES    OF    THE    NEUROSES. 

greater  or  less  extent  the  intervals  between  them.  In 
a  very  large  proportion  of  cases  we  can  hardly  call 
these  patients  insane  during  these  intervals;  they  are 
rational;  fairly  intelligent;  their  recollection  of  events 
occurring  during  this  stage  and  of  previous  events  is 
good;  they  understand  their  condition  and  are  willing 
often  to  do  what  they  can  to  mend  it;  they  exercise 
more  or  less  self-control;  in  short,  they  are  rationally 
sane  individuals  in  all  or  nearly  all  respects.  In  some 
cases,  indeed,  one  cannot  call  them  at  all  insane  or 
abnormal  during  these  intervals,  though  they  may  be 
dangerously  so,  at  times,  in  connection  with  their 
attacks.  In  many  other  cases,  however,  and  in  most 
after  long  continuance  of  the  disease,  there  is  a  mental 
state  or  disorder  of  the  intervals  as  well  as  of  the 
attacks.  Sometimes  this  is  only  a  mild  grade  of  de- 
mentia; the  patient  is  simply  weak-minded  or  semi- 
imbecile,  often  amiably  so,  but  more  often  irritable  and 
liable  to  fly  into  a  violent  passion  on  the  slightest  provo- 
cation, which  renders  him  to  some  extent  dangerous 
and  requiring  restraint.  Frequently  both  qualities 
are  combined ;  the  patient  is  jovial  and  happy  as  a  rule, 
but  "ready  to  fight  at  the  drop  of  a  hat,"  as  the  saying 
is.  One  such  patient,  a  happy,  careless-dispositioned 
epileptic  with  very  moderate  signs  of  dementia,  told 
the  writer,  we  believe  truthfully,  that  he  had  served  at 
least  forty  bridewell  sentences,  mostly  for  fighting  and 
disorderly  conduct.  His  scalp  was  one  mass  of  scars, 
largely,  if  not  solely,  obtained  in  this  way,  but  in  the 
asylum,  under  judicious  management,  he  was  a  very 
tractable  and  useful  individual. 

Very  often,  however,  the  condition  between  fits  shows 
a  more  manifest  change  of  character  or  abnormality, 
and  this  has  rather  formed  the  popular  opinion  of  the 
epileptic,  as  an  unpleasant  and  morally  as  well  as 
mentally  deteriorated  individual.  We  must  remember 
that  the  chief  symptom  is  irritability  and  loss  of  control 


EPILEPTIC    INSANITY.  263 

to  a  large  extent,  and  this,  superimposed  upon  the 
natural  disposition,  handicapped  by  the  disease,  and 
often  aggravated  by  bad  management  and  misunder- 
standing, and  often  by  actual  maltreatment,  is  not  a 
favorable  condition  for  the  development  of  the  more 
amiable  traits.  It  is  not  surprising,  therefore,  that 
the  epileptic  is  considered  a  rather  unamiable  charac- 
ter ;  it  is  more  surprising  that  we  find  so  many  who  are 
not  such .  Add  to  this  irritability  a  certain  degree  of  men- 
tal weakness,  and  the  chances  of  unpleasant  modifica- 
tions of  the  natural  disposition  are  increased.  Many 
epileptics  suffer  from  occasional  hallucinations  connected 
with  their  attacks  of  acute  mental  disorder,  which 
will  be  described  later,  and  these  have  sometimes 
an  influence  over  them  in  intervals  between.  There  is 
sometimes  an  offensive  egotism,  but  this  is  no  more 
frequent  in  these  patients  than  in  most  other  forms  of 
chronic  mental  derangement,  and  it  must  be  said  in  favor 
of  the  epileptics  generally,  that  they  are  rather  more  sym- 
pathetic toward  each  other  and  toward  others  than  the 
insane  generally.  Their  inconsistent  religiosity  that 
has  often  been  noticed  to  their  disparagement  is,  in 
many  cases  at  least,  only  evidence  of  an  honest  attempt 
to  better  their  lives,  baffled  by  their  infirmities.  It  is 
not  uncommon  in  asylums  to  see  explosions  of  violent 
temper  with  profanity  in  patients  when  disturbed,  for 
example,  at  their  somewhat  ostentatious  devotions, 
and  this  has  been  remarked  upon,  somewhat  unjustly, 
to  their  discredit.  We  have  known  violent,  irritable 
epileptics  to  voluntarily  seclude  themselves  on  this 
account,  and  forego  many  privileges  they  appreciated, 
to  avoid  provocation  that  might  cause  acts  they 
regretted.  In  some  cases,  it  is  true,  there  is  developed 
a  vicious  or  excessively  disagreeable  disposition;  they 
are  unreliable  and  treacherous,  or  peevish  and  childish, 
always  wanting  and  asking  sympathy  or  demanding 
attention   in    a    most    persistent    and    offensive   way. 


264  INSANITIES    OF    THE    NEUROSES. 

These  cases  are,  however,  in  the  minority,  and  opposed 
to  them  we  have  some  rather  admirable  characters,  in 
spite  of  their  infirmities.  It  is  common,  and  rather 
the  rule,  to  find  in  the  lesser  grades  of  epileptic  demen- 
tia a  certain  degree  of  obstinacy  in  small  matters, 
which  is  very  apparent,  unless  they  are  tactfully 
managed.  This  is  one  of  the  characters  that  specially 
marks  this  demented  type,  aside  from  the  acute  epi- 
sodes. 

When  actual  insanity  other  than  the  dementia  de- 
scribed exists  during  the  intervals  between  the  attacks 
it  is  very  frequently  of  a  hallucinatory  type,  and  gen- 
erally attended  with  delusions.  Often  these  are  of 
a  persecutory  character ;  the  patient  hears  voices  abus- 
ing and  insulting  him,  and  finally  gives  way  to  a  belief 
in  their  reality.  A  patient  of  this  type,  who  had 
never  been  declared  insane  and  was  at  large,  com- 
plained to  the  writer  that  while  he  knew  or  thought  he 
knew  the  voices  he  heard  were  unreal,  yet  he  was  in 
constant  fear  that  he  would  do  something  under  their 
direction  that  would  get  him  into  trouble.  His  dis- 
position was  good  and  he  still  retained  self-control ;  his 
disorder  was  as  yet  a  purely  hallucinatory  one,  and  he 
realized  that  it  was  sure  to  get  the  better  of  him  sooner 
or  later,  as  it  doubtless  did,  though  as  he  passed  out 
of  knowledge  his  later  history  is  unknown.  Another 
patient,  who  came  to  the  hospital  with  a  record  of 
having  been  violent,  was  one  of  the  best  inmates;  he 
was  docile,  industrious,  and  of  a  most  excellent  natural 
disposition.  He  was  conscientious  to  a  degree  and 
perfectly  reliable,  and  fully  equal  to  an  attendant  in 
handling  violent  patients ;  he  had  the  knack  of  manag- 
ing them  better  than  most  attendants,  and  as  he  was 
of  remarkable  strength,  he  could  master  the  most 
violent  without  exerting  himself  or  injuring  them. 
His  sympathy  and  tact  were  also  remarkable;  apart 
from    his    disorder,    he    was    almost    a    natural-born 


EPILEPTIC    INSANITY.  265 

attendant,  and  was  considered  a  treasure  in  the  ward. 
This  was  the  more  striking  as  he  was  a  full-blooded 
negro,  and  had  race  prejudice  against  him,  which,  how- 
ever, he  generally  conquered  even  in  his  Irish  fellow- 
patients,  by  his  gentle  and  tactful  behavior.  Yet 
this  man  would  at  times  talk  to  himself  at  length  in 
almost  a  whisper,  saying  such  things  as,  "I  don't  know 
what  they  can  have  against  me,"  and  "Why  do  they 
treat  me  so?  what  have  I  done?"  etc.  He  did  not  care 
to  be  overheard,  and  would  not  explain  his  trouble, 
but  from  his  actions  and  manner,  as  well  as  sotto  voce 
remarks,  he  was  evidently  severely  troubled  with 
auditory  hallucinations.  In  his  case  the  disease  never 
advanced  beyond  this  point;  he  was  not  demented, 
though  limited  in  his  acquirements,  and  he  was  not, 
while  under  observation,  any  worse  in  connection  with 
his  epileptic  attacks. 

Such  cases  as  the  above  are,  however,  exceptional  in 
their  self-control  as  well  as  in  their  remarkably  amiable 
traits,  but  they  do  occur  among  epileptics,  and  there 
are  many  others  under  tactful  management  who  can 
be  made  to  more  or  less  approach  them  in  these  re- 
spects. Under  the  control  of  a  rough  or  brutal  jailer 
or  poor-house  warden  the  above-described  patient 
would  very  likely  have  been  troublesome,  and  his 
record  of  violence  was  probably  due  to  such  a  cause. 
There  are  other  cases  in  which  the  mental  disorder 
takes  on  a  less  agreeable  phase,  and  in  which  the 
patients  are  more  morally  than  intellectually  deranged. 
When  this  is  combined  with  excessive  irritability, 
these  patients  are  particularly  dangerous.  Most  epi- 
leptics are  open  to  good  influences,  and  often  hysteric- 
ally religious  at  times,  but  these  fortunately  excep- 
tional cases  have  not  these  redeeming  traits.  They 
may  be  called  cases  of  epileptic  moral  insanity,  and 
their  best  feature  is  that,  until  they  become  too  de- 
mented to  be  dangerous,  they  are  generally  amenable 


266  INSANITIES    OF    THE   NEUROSES. 

to  asylum  discipline  and  not  likely  to  do  what  in  their 
idea  might  lead  to  inconvenient  consequences.  They 
are,  however,  evaders,  unreliable,  brutal  to  their  weaker 
associates,  and  vicious  when  they  see  no  disadvantage 
from  their  misbehavior.  They  are  often  masturbators, 
and  in  some  cases  most  persistent  ones,  but  this  is  also 
common  in  epileptic  dementia  of  the  ordinary  type. 

Another  not  very  uncommon  type  is  the  whining, 
disagreeable  epileptic,  not  characteristically  violent 
except  on  rare  occasions,  but  always  persistently  ego- 
tistic and  demanding  sympathy  and  attention.  In 
some  cases  they  are  treacherous  and  hypocritical,  and 
are  generally  trying  to  the  patience  of  those  that  have 
to  care  for  them  or  in  any  way  to  do  with  them.  These 
two  types  are  prominent  enough  among  epileptics  to  be 
taken,  together  with  the  irritable  dements,  as  setting 
the  type  of  the  whole  class  of  insane  epileptics — a 
manifest  injustice,  as  they  form  only  a  very  moderate 
proportion  of  the  whole,  and  with  good  management, 
as  will  be  mentioned  later,  their  number  is  still  further 
reduced.  The  incorrigible  moral  epileptic  lunatics  are 
rare  exceptions. 

The  really  characteristic  epileptic  insanity,  however, 
is  that  appearing  in  connection  with  the  epileptic 
attacks,  or  in  their  place — the  so-called  larvated  epi- 
lepsy. This  may  appear  before  or  after  the  paroxysms, 
or,  as  just  said,  may  replace  them ;  thus,  we  have  pre- 
and  post-epileptic  insanity  and  the  epileptic  equiva- 
lent. The  first  named  is  not  uncommon,  and  may 
show  itself  in  exalted  or  maniacal  conditions,  or,  as  is 
more  common,  in  depression  appearing  at  varying 
periods  prior  to  the  convulsions.  In  some  cases,  also, 
there  may  be  hallucinations  of  various  kinds,  or  there 
may  be  only  an  excess  of  irritability,  gradually  increas- 
ing to  an  explosion  of  violence  in  some  form  or  other. 
In  this  last  case  the  patient  may  be  entirely  rational, 
and  endeavor  to  control  himself  till  finally  the  condi- 


EPILEPTIC    INSANITY.  267 

tion  culminates  in  an  explosion  of  violence  beyond  his 
control  and  often  directly  connected  with  the  epileptic 
attack  itself.  The  duration  of  this  pre-epileptic  con- 
dition ranges  in  different  cases  from  a  few  minutes  or 
hours  to  several  days,  or  even  longer ;  sometimes  it  may 
be  considered  as  simply  a  prolonged  aura,  or  in  other 
cases  as  an  independent  attack  of  insanity  of  more  or 
less  brief  duration.  A  very  large  proportion  of  epileptics 
have  some  form  or  other  of  pre-epileptic  disturbance, 
but  in  the  majority  it  does  not  go  so  far  as  to  be  actual 
insanity.  Generally  it  is  only  a  slight  depression  or  a 
physical  and  mental  restlessness,  hard  to  describe,  but 
very  real  to  the  subject  himself.  In  many  cases  of 
pronounced  pre-epileptic  derangement  there  are  hal- 
lucinations, sometimes  disagreeable,  but  sometimes, 
also,  agreeable,  and  even  ecstatic  visions  or  sounds  are 
experienced  in  this  stage.  Dostoievski,  the  Russian 
novelist,  who  was  a  confirmed  epileptic,  is  said  to  have 
had  these  ecstatic  hallucinations,  and  to  have  declared 
that  for  this  reason  no  amount  of  money  could  induce 
him  to  part  with  a  single  one  of  his  fits  and  their  blissful 
pre-epileptic  sensations.  It  is  possible  that  the  visions 
of  Mahomet  and  of  Swedenborg  and  other  modern 
prophets  and  saints  are  to  be  accounted  for  in  this  way. 
In  many  other  cases  the  sensations  are  very  un- 
pleasant. In  one  case  under  observation,  the  epi- 
leptic, ordinarily  a  very  irritable  and  often  rather  un- 
manageable patient,  suffered  from  the  most  terrifying 
feelings, — half -fledged  hallucinations  they  might  be 
called, — in  which  he  seemed  to  be  surrounded  or  at- 
tended by  beings  whom  he  could  not  appreciate  by  any 
of  his  external  senses,  but  who  were  very  real  and  ter- 
rifying to  him.  He  would  walk  back  and  forth,  pray- 
ing for  help  and  relief,  and  while  not  at  all  suicidal, 
was  liable  to  do  himself  an  injury  in  his  frantic  parox- 
ysms of  terror.  He  was  conscious  and  would  talk 
rationally,  but  was  utterly  unable,  either  at  the  time 


208  INSANITIES    OF   THE    NEUROSES. 

or  later,  though  his  recollection  seemed  acute,  to  de- 
scribe his  sensations  or  explain  the  cause  of  his  terror. 
Other  more  or  less  similar  cases  might  be  given,  but 
this  one  will  suffice. 

The  epileptic  equivalent,  or  psychic  epilepsy,  is  gener- 
ally a  sudden  and  often  very  brief  attack  of  insanity, 
occasionally  of  melancholia,  but  more  often,  or  at  least 
more  noticeably,  of  mania  or  furor.  In  other  cases 
there  is  a  temporary  hallucinated  condition,  a  sort  of 
brief  paranoia;  and  in  still  others,  a  sudden  explosion 
of  causeless  automatic  violence  is  the  only  pheno- 
menon. The  most  typical  cases  are  those  of  furor, 
in  which  the  patient  passes  very  rapidly  into  a  state 
of  violent  mania  or  impulsive  violence  of  short  dura- 
tion, and,  as  a  rule,  has  no  memory  of  his  acts  per- 
formed while  in  this  state.  In  some  cases  the  acts  of 
violence  appear  purposive,  and  as  if  contemplated 
beforehand,  but  the  amnesia  is  generally  complete 
afterward.  This  is  not  always  the  case,  for  sometimes 
the  patients  have  a  perfect  recollection  of  all  their  acts 
in  this  state.  It  has  been  often  said  by  good  authori- 
ties that  these  acts  are  always  unconscious,  and  that 
unconsciousness  is  a  necessary  condition  of  epileptic 
manifestations.  Leaving  aside,  however,  the  necessary 
distinction  to  be  made  between  unconsciousness  and 
amnesia,  it  is  incorrect  to  say  that  unconsciousness  is 
an  essential  feature  of  any  form  of  epilepsy.  There  is, 
in  the  severer  forms, — and  in  them  we  can  include 
these  larvated  ones, — generally  a  loss  and  almost 
always  a  disturbance  of  consciousness,  but  in  rare  in- 
stances it  is  not  safe  to  say  that  even  this  latter  occurs 
to  any  extent;  even  in  epileptic  furor  consciousness 
may  be  as  perfect  as  is  possible  under  such  a  grade  of 
excitement,  as  is  proved  by  observation  as  well  as  by 
the  testimony  of  the  patients  themselves.  Neverthe- 
less, in  most  cases  there  is  amnesia ;  at  least,  the  patient 
recalls  nothing  of  his  acts  after  coming  out  of  his 


EPILEPTIC    INSANITY.  269 

attack,  and  this  is  so  much  the  rule  that  it  may  be  pre- 
sumed in  all  cases  where  there  is  not  proof  to  the  con- 
trary. This  form  of  epileptic  attack  is  of  very  great 
forensic  importance ;  a  large  proportion  of  the  cases  of 
temporary  insanity  with  violence  are  of  this  nature. 

The  post-epileptic  mental  disturbance  is  the  most 
frequent  of  the  three  forms,  and  therefore  the  most  im- 
portant. It  is  the  rule  that  an  epileptic  fit,  especially 
the  grand  mat,  or  fully  developed  epileptic  attack, 
leaves  after  it  some  temporary  cerebral  disturbance; 
most  commonly  there  is  a  shorter  or  longer  stuporous 
interval,  or  there  may  be  a  severe  headache  and  more 
or  less  mental  confusion  for  a  short  time.  When  the 
case  comes  fairly  under  the  category  of  post-epileptic 
insanity,  the  mental  manifestations  may  be  widely 
varying.  We  may  see  in  rare  cases  an  acute  hallucina- 
tory confusional  state ;  in  another,  extreme  depression ; 
in  another,  motor  excitement,  as  shown  in  epileptic 
furor,  with  a  specially  marked  violent  tendency;  and 
in  still  others,  a  paranoiac  state  lasting  from  a  few 
hours  to  several  days  or  more.  The  epileptic  furor  is 
the  most  characteristic,  and  suggests  in  its  phenomena 
some  terrifying  delusion  or  hallucination  of  the  patient 
or  some  delusion  of  injury  or  attack  by  others.  A 
peculiarity  of  these  cases  is  the  fierceness  and  vindic- 
tiveness  of  their  attacks  on  others,  which  seem  often 
utterly  beyond  reason  and  out  of  character.  There 
appears  to  be  a  sort  of  moral  deterioration  in  this  state 
that  thus  manifests  itself ;  the  patient  may  be  ordinarily 
amiable  and  docile,  but  in  these  attacks  one  becomes 
not  only  furious,  but  causelessly  and  viciously  intent 
on  injury  to  persons  or  objects  that  are  in  his  way. 
This  is  not  always  the  case,  but  it  is  sufficiently  fre- 
quent to  be  considered  characteristic,  and  to  be  men- 
tioned as  such  in  most  of  the  text-books.  One  who  has 
closely  observed  epileptics  in  this  condition,  however, 
can  see  individual  traits  even  here,  and  it  is  worthy  of 


270  INSANITIES    OF    THE    NEUROSES. 

note  here  that,  at  least  in  a  very  large  proportion  of 
cases,  there  is  not  that  reckless  disregard  of  danger 
that  is  so  commonly  said  to  exist  in  the  post-epileptic 
furor.  The  patient,  however  furious  he  may  appear, 
is  very  apt  to  still  retain  some  degree  of  prudence,  and 
does  not  attack  those  who  are  likely  to  be  dangerous  to 
him.  We  have  seen  an  epileptic  in  this  condition  com- 
pletely cowed  by  another  more  powerful  patient,  and 
actually  docile  to  a  fearless  and  muscular  attendant. 
In  some  few  cases,  however,  they  seem  possessed  with 
a  blind,  unreasoning  furor,  and  are  regardless  appar- 
ently of  consequences.  These  cases  are  very  apt  to  be 
destructive  to  property  in  these  states,  and  sometimes 
work  off  their  excitement  entirely  in  trying  to  wreck 
their  room  with  its  plastering  and  furniture. 

The  forensic  importance  of  these  conditions  is  very 
great,  and  much  stress  is  laid  upon  the  loss  of  con- 
sciousness as  affecting  responsibility.  It  should  be 
borne  in  mind,  however,  that,  whether  consciousness 
is  lost  or  merely  clouded,  or  if  amnesia  only  exists 
later,  the  condition  is  one  of  mental  disease,  and  any 
remnants  of  self-control  that  may  exist  do  not  materi- 
ally affect  the  case — the  patient  is  legally  irresponsible. 

The  diagnosis  of  epileptic  insanity  is  usually  easy; 
the  obvious  association  of  the  convulsions  which  are 
almost  always  a  prominent  feature  of  the  case,  and  in 
a  large  proportion  of  the  cases  the  peculiarities  of  the 
mental  derangement  itself,  are  sufficient  to  cause  its 
recognition.  In  no  other  form  of  mental  disorder  is 
the  keynote  of  irritability  so  evident.  There  is  also 
a  peculiar  facial  expression  to  the  insane  epileptic  that 
is  recognizable  by  one  familiar  with  them,  not  readily 
described,  but  very  manifest.  It  consists  largely  in  a 
sort  of  intense  expression  of  the  eyes  and  a  forced  look 
that  is  hardly  ever,  if  at  all,  seen  in  others  than  epi- 
leptics. It  may  be  said  here,  to  aid  the  description, 
that  this  peculiar  expression  is  to  a  certain  degree 


EPILEPTIC    INSANITY.  271 

counterfeited  in  Delaroche's  celebrated  picture  of 
Napoleon  at  St.  Helena,  engravings  of  which  are  com- 
mon in  this  country.  We  are  not  aware  that  this 
resemblance  was  intentional,  but  the  fact  that  Napo- 
leon was  said  to  be  an  epileptic  makes  it  rather  the 
more  remarkable.  As  evidence  that  this  epileptic 
facies  is  a  real  thing,  it  may  be  said  here  that  one  of 
the  writers  once  took,  by  a  rather  primitive  method,  a 
composite  photograph  of  nine  epileptics.  The  very 
vague  picture  produced  was  shown,  without  stating  the 
facts,  to  several  persons  in  the  asylum  familiar  with 
epileptics,  but  who  knew  nothing  of  its  origin,  and  they 
all  declared  it,  on  questioning  them,  a  very  poor  like- 
ness of  some  epileptic  or  other,  one  or  two  of  them 
recognizing  in  it  a  likeness  to  an  epileptic  patient  not 
included  in  the  number  that  contributed  to  its  forma- 
tion. 

Much  has  been  said  about  the  identical  character  of 
the  attacks  in  the  individual  epileptics,  and  to  a  certain 
extent  this  is  a  fact,  and  is  also  an  aid  in  the  diagnosis. 
The  cerebral  mechanism  may,  however,  vary  at  dif- 
ferent times  in  the  same  individual,  and  therefore  the 
photographic  similarity  of  symptoms  is  not  always  to 
be  relied  upon.  The  chief  elements  of  the  diagnosis 
are  those  mentioned  above.  There  is  a  possibility  of 
non-recognition  of  the  epileptic  factor  in  some  cases 
of  chronic  dementia,  delusional  and  other  forms  of 
insanity  that  were  originally  epileptic,  but  these 
hardly  come  under  this  head  in  their  final  condition, 
and  in  a  general  way  it  may  be  said  that  the  diagnosis 
presents  no  particular  difficulties. 

The  prognosis  of  epileptic  insanity  is  generally  bad. 
Epilepsy  itself  is  so  rarely  a  curable  condition  that 
when  it  has  progressed  so  far  as  to  produce  insanity 
the  result  is  generally  considered  hopeless  as  regards 
recovery.  It  is  doubtful,  however,  whether  we  can 
rightly  call  it  absolutely  hopeless.     The  insanity  con- 


272  INSANITIES    OF    THE    NEUROSES. 

nected  with  the  epileptic  attack  is  not  necessarily  per- 
manent, and  when  dementia  has  not  already  become 
apparent,  there  is  at  least  a  remote  chance  of  cure. 
We  have  seen  at  least  one  epileptic  with  an  insane 
record  so  far  recover  from  his  disorders  as  to  be  free 
from  both  epileptic  attacks  and  mental  disturbances 
for  over  three  years,  or  as  long  as  he  was  under  observa- 
tion. It  cannot,  of  course,  be  said  that  there  was  a 
lasting  cure  in  this  case,  but  recovery  was  as  complete 
as  often  occurs  in  many  other  forms  of  insanity. 
Reference  has  already  been  made  to  occasional  cases 
of  terminal  dementia  that  originated  in  epileptic  in- 
sanity, where  the  neurosis  has  disappeared  for  years. 
It  is  possible  that  epilepsy  may  sometimes  exist  and 
be  associated  with  mental  derangements  and  then 
leave  the  patient,  under  the  influence  of  treatment,  or 
for  other  causes,  as  is  sometimes  the  case,  and  no 
serious  mental  disorder  be  left. 

The  chances  of  permanent  recovery  of  reason  in 
epileptic  insanity  are,  however,  so  slight  that  the  con- 
dition may  be  considered  generally  a  hopeless  one,  and 
absolutely  so  when  any  degree  of  dementia  has  been 
reached. 

Treatment. — The  cases  of  epileptic  insanity  should 
be  treated  in  a  hospital  for  the  insane  or  a  special  epi- 
leptic hospital ;  so  dangerous  are  they,  that  the  risk 
of  their  home  treatment  or  their  treatment  in  an 
ordinary  hospital  is  too  great  for  it  to  be  undertaken. 

The  treatment  divides  itself  into  that  of  the  violent 
manifestations  and  that  of  the  interval.  The  careful 
observer  can  usually  determine  the  approach  of  an  at- 
tack ;  then  isolation  and  restraint  must  be  resorted  to 
without  delay;  the  attack  usually  soon  subsides,  and 
we  doubt  if  any  medication  will  cut  short  the  duration 
of  these  manifestations  or  much  diminish  the  violence, 
though  hypodermics  of  hyoscin  hydrobromate  or 
morphin  sulphate  are  of  some  service  occasionally. 


EPILEPTIC    INSANITY.  273 

The  most  available  time  for  treatment  is  during  the 
intervals.  The  most  popular  drugs  with  the  profession 
are  the  bromids  of  potassium,  sodium,  strontium,  and 
ammonium;  they  are  efficient,  but  they  must  be  used 
with  judgment.  There  is  no  doubt  that  some  of  the 
cases  of  epileptic  insanity  are  the  result  of  an  unreason- 
able use  of  the  bromids.  A  few  cases  of  epilepsy  have 
been  cured  by  the  bromids,  many  have  been  improved, 
and  some  have  been  irrecoverably  injured.  It  is  well 
in  these  cases  to  add  to  the  bromids  some  cardiac 
stimulant,  such  as  Tinct.  cannabis  indica  nuxv  (i.oo), 
or  Tinct.  hyoscyamus  nsxx  (1.33) ;  and  the  amount  of 
bromids  used  should  never  be  sufficient  to  produce  much 
acne  or  complete  f  aucial  anesthesia.  With  this  moder- 
ate bromid  and  cardiac  stimulant  an  antiseptic,  such  as 
salol  gr.  j-iv  (0.06-0.25),  or  bismuth  beta-naphthol 
gr.  v  (0.31),  should  be  given,  and  the  diet  should  be 
carefully  regulated,  using  only  the  most  easily  digestible 
food  and  reducing  the  nitrogenous  intake  to  the  lowest 
possible  amount  consistent  with  good  general  nutrition ; 
the  amount  of  sugar  consumed  should  also  be  very 
small,  as  this  interferes  with  the  complete  metabolism 
of  the  nitrogenous  foods. 

Careful  attention  should  be  given  to  elimination  by 
skin,  kidney,  and  bowels.  Turkish  baths,  body  mas- 
sage, alkaline  diuretics,  and  laxatives  with  colonic 
flushing,  meet  these  indications. 

There  is  some  advantage  in  epilepsy  in  the  counter- 
irritation  of  the  nape  of  the  neck  by  the  actual  cautery. 
We  are  sure  that  this  plan  of  treatment  is  too  little 
used  in  these  cases;  such  irritation  twice  a  week  will 
diminish  if  not  relieve  headache,  and  certainly  will 
prolong  the  interval  between  attacks. 

It  has  been  said  above  that  some  cases  of  epileptic 

insanity  have  doubtless  been  caused  by  the  injudicious 

and  excessive  use  of  the  bromids.     This  does  not  mean 

merely  production  or  aggravation  of  mental  failure, 

18 


274  INSANITIES    OF    THE    NEUROSES. 

but  includes  also  cases  of  acute  maniacal  explosions 
due  to  the  drug.  That  large  doses  of  bromid  could 
have  this  effect  was  noticed  as  earry  as  1869  by  French 
authors  and  by  Hammond,  and  attention  was  espe- 
cially called  to  the  fact  by  one  of  us  in  1881,  and  in  the 
discussion  on  his  paper  in  the  American  Neurological 
Association  the  opinion  was  expressed  by  some  that  a 
certain  proportion  of  cases  of  epileptic  insanity  in  our 
asvlums  were  merely  cases  of  bromid  mania.  More 
recently  this  action  of  the  bromids  has  been  written 
upon  by  Weir  Mitchell,  Harriett  C.  B.  Alexander,  and 
others,  and  there  is  in  our  minds  little  doubt  that  these 
agents,  either  by  the  suppression  of  the  attacks  from 
their  use,  or  from  some  special  action  of  their  own  on 
the  nerve-centers,  do  occasionally  cause  mania  or  epi- 
leptic furor.  From  cases  observed  by  us,  we  also  think 
it  probable  that  they  have  been  sometimes  responsible 
for  the  dangerous  insane  symptoms  of  certain  epi- 
leptics, who  but  for  their  use  might  possibly  not  have 
given  cause  for  any  suspicions  of  activeinsanity. 

The  moral  treatment  of  insane  epileptics  is  of  the 
very  greatest  importance,  and  in  some  cases  is  prac- 
tically all  the  treatment  possible  or  effective.  In 
hardly  any  other  form  of  mental  disease  is  tact  in 
management  more  important  or  conducive  to  better 
results,  for  the  time  being.  Some  epileptics  are  too 
demented  to  appreciate  it ;  a  very  few  are  incorrigibly 
bad,  and  only  amenable  to  comparatively  rigid  dis- 
cipline in  the  way  of  isolation  and  restraint  amongst 
those  they  cannot  or  dare  not  abuse;  but  the  great 
majority,  while  irritable  and  subject  to  violent  fits  of 
passion,  are  very  appreciative  of  kindness  and  justice 
in  the  intervals  of  their  attacks.  They  can  usually  be 
reasoned  with  and  made  to  appreciate  the  fact  that 
their  disease  renders  them  troublesome  or  dangerous  to 
others,  and  that  they  must  submit  to  the  necessary 
rules    and   restrictions   their   condition    demands.     If 


HYSTERIC    INSANITY.  275 

they  once  feel  that  their  doctors  and  attendants  are 
their  friends,  they  are  comparatively  easy  to  control, 
if  managed  tactfully  during  their  spells.  It  is  best  in 
all  cases  for  them  to  know  that  they  are  under  rules, 
and  to  expect  that  if  these  are  relaxed  in  their  favor, 
it  is  as  a  favor,  and  not  as  a  right.  There  are  many 
epileptics  of  this  kind  that  can  be  allowed  considerable 
liberty  under  supervision,  but  it  is  not  advisable  to 
allow  this  except  as  a  special  privilege,  for  if  it  is 
understood  to  be  a  right,  the  necessary  denial  at  times 
will  be  sure  to  cause  trouble.  We  must  keep  in  mind 
the  fact  that  epileptic  irritability  is  very  easily  aroused, 
especially  when  they  feel  that  they  are  wronged,  and 
the  keynote  of  their  management  is  to  make  them  feel 
that  they  are  among  friends  who  act  only  for  their  good. 
With  such  an  understanding  they  are  in  most  cases 
docile  and  manageable  patients. 


HYSTERIC  INSANITY. 

Inasmuch  as  hysteria  is  a  condition  itself  most  diffi- 
cult to  define,  it  follows  naturally  that  the  definition  of 
hysteric  insanity  is  also  difficult.  We  can  say  in 
general  terms  that  various  forms  of  insanity  may 
develop  upon  a  hysteric  basis,  and  that  in  this  respect 
it  corresponds  closely  with  its  allied  neuropsychosis, 
epileptic  insanity.  It  differs  from  epileptic  insanity, 
however,  in  being  much  more  decidedly  a  degenerative 
type,  as  hysteria  is  itself  more  of  a  degenerative 
psychoneurosis  than  is  epilepsy.  The  definition  may 
be  stated,  perhaps  as  well  as  in  any  other  terms,  as 
follows :  Hysteric  insanity  is  to  a  great  extent  a  degen- 
erative psychosis  proceeding  from  hysteria  or  colored 
by  it  in  such  a  way  as  to  be  clearly  distinguishable  from 
other  similar  conditions  of  different  origin  or  complica- 
tion. Ordinary  mania  and  melancholia  are  quite  dis- 
tinct clinically  from  the  corresponding  hysteric  types, 


276  INSANITIES    OF   THE    NEUROSES. 

and  hysteric  reasoning  mania  is  characteristically 
different  from  hypomania. 

The  first  and  most  prominent  cause  of  hysteric  in- 
sanity is  heredity.  In  nearly  every  case  there  is  a 
history  of  neurosis,  insanity,  or  intemperance,  and  very 
often  a  direct  heredity  of  hysteria.  Where  these  are 
lacking,  there  is  a  neurotic  congenital  weakness  in 
nearly  every  case.  Aside  from  this,  trauma  may  be 
considered  the  most  efficient  cause,  but  it  is  an  infre- 
quent one  where  the  congenital  predisposition  is  lack- 
ing. Other  causes,  such  as  exhausting  sickness,  tox- 
emia, shock,  etc.,  are  probably  only  effective,  at  least 
to  any  extent,  as  secondary  to  predisposition  and 
heredity.  Traumatic  hysteria  has  a  forensic  impor- 
tance that  renders  it  prominent,  and  thus  has  given,  it 
may  be,  the  impression  that  the  cause  is  itself  more 
frequent  than  it  really  is — that  is,  as  an  independent 
etiologic  factor.  When  traumatism  causes  insanity  in 
an  individual  with  this  degenerative  hysteric  predis- 
position, we  will  be  very  likely  to  consider  the  develop- 
ment as  due  to  it  more  than  is  actually  the  case.  It 
is  the  degenerative  factor,  not  the  accidental  or  exciting 
cause,  that  is  the  real  basis  of  the  disorder. 

Hysteria  itself  is  a  mental  disease ;  its  striking  char- 
acteristics are  overactivity  of  the  emotions  and  im- 
pairment of  intellectual  and  volitional  power,  with 
frequently  an  enhanced  acuity  of  the  perceptions. 
Those  unfortunate  people  who  are  its  victims  are, 
therefore,  creatures  of  impulse,  controlled  by  their 
feelings  and  not  by  their  reason.  This  very  mental 
condition  is  so  close  to  insanity  that  it  is  not  always 
easy  to  draw  the  line  of  demarcation,  and  it  is,  there- 
fore, not  surprising  that  hysteria  frequently  develops 
into  unquestioned  insanity.  When  this  occurs,  the 
manifestations  are  like  the  parent  stock;  impulsiveness, 
unreasonableness,  extreme  selfishness,  excessive  sexu- 
ality, suggestibility ;  illusions,  hallucinations,  and  delu- 


HYSTERIC    INSANITY.  277 

sions,  especially  in  the  visceral  area,  are  common.  The 
landmarks  of  hysteria  can  sometimes  be  found,  such 
as  faucial  anesthesia;  tremor  of  the  closed  eyelid; 
tenderness  under  the  left  mammary  gland,  at  the  epi- 
gastrium, over  the  left  ovary;  limitation  of  the  field 
of  vision,  and  are  invaluable  in  differential  diagnosis. 

Hysteric  insanity  is  very  frequently  recurrent,  the 
attacks  occurring  at  intervals  under  special  conditions, 
such  as  menstrual  periods,  etc.  It  may  take  either  the 
maniacal  or  the  melancholic  form,  each,  however, 
colored  by  the  general  pre-existing  neurosis,  as  indi- 
cated above.  Hallucinations,  dreamy  states,  illusions, 
etc.,  are  not  infrequent  in  these  conditions,  and  there 
is  in  some  cases  quite  a  resemblance  to  certain  types 
of  epileptic  pre-  or  post-paroxysmal  delirium.  The 
characteristic  feature  of  even  these  cases  is  often  the 
effect  of  observation  and  sympathy  upon  the  patient, 
and  their  openness  to  suggestions  in  some  direction, 
even  in  their  apparently  fully  developed  mania  or 
melancholia.  We  might  call  the  attacks  in  these  cases 
a  shallow  or  superficial  type  as  compared  with  the 
intensity  and  reality  of  the  genuine  forms,  though 
sometimes  the  resemblance  is  very  close.  There  may 
be,  and  often  are,  destructive  tendencies  in  these  states, 
but  the  outrageous  violence  of  the  epileptic  is  seldom, 
if  ever,  observed. 

In  other  cases  we  have  trance  conditions  and  cata- 
lepsy, and  seeing  ecstatic  visions,  as  in  some  of  the 
noted  visionaries,  and  there  is  a  wide  range  of  conditions 
that  seems  to  be  on  the  borderland  of  hysteria  and 
epilepsy — apparent  conditions  of  double  consciousness, 
somnambulistic  states,  etc. — that  can  probably  be  best 
included  under  this  head.  The  exact  tendencies  of 
hysteria  itself  are  not  clear,  and  we  cannot,  therefore, 
say  positively  as  to  the  correct  reference  of  some  of 
these  conditions  or  symptoms. 

The  most  typical  form  of  hysteric  insanity  is  the 


278  INSANITIES    OF    THE    NEUROSES. 

hysteric  reasoning  mania,  or,  as  it  might  be  called, 
hysteric  moral  insanity.  In  this  all  the  specially  char- 
acteristic moral  weaknesses  of  the  hysteric  subject  are 
prominent,  together  with  many  of  the  physical  and 
other  stigmata  of  the  condition ;  and  with  these,  a  more 
or  less  complete  retention  of  the  reasoning  power  and 
a  certain  misdirected  self-control,  so  to  speak,  a  sort  of 
perverted  and  abnormal  will-power.  These  patients  are 
egoistic  to  the  extreme,  and  are  the  most  annoying  to 
those  who  have  to  care  for  them  or  live  with  them  of 
almost  any  class  of  the  insane.  They  are  excessively 
notional  and  full  of  projects ;  they  often  show  a  marked, 
and  perverted  sort  of  religiosity ;  are  apt  to  be  full  of  a 
sort  of  unpleasant  self -righteousness  and  sometimes  an 
ostentatious  professed  philanthropy.  Some  of  these 
patients  at  large  are  for  a  time  active  workers  in  church 
matters  or  in  public  or  private  benevolences,  but  their 
moral  and  emotional  perversion  soon  makes  its  appear- 
ance and  destroys  their  influence  and  usefulness. 
Attention  is  what  they  demand,  and  it  is  impossible 
to  satisfy  them  with  enough  of  it ;  they  are  full  of  im- 
aginary bodily  ailments  and  have  undoubtedly  many 
marked  sensory  hallucinations,  or  what  may  be  so 
called,  of  disease  in  various  organs,  and  are  the  most 
persistent  drug  habitues  if  they  have  the  opportunities. 
Their  sleep  is  very  commonly  disturbed ;  their  appetite 
variable,  though  generally  sufficient  for  their  nutrition. 
The  typical  nagging  woman  is  often  a  mild  form  of  this 
phase  of  hysteric  reasoning  mania,  not  pronouncedly 
insane  enough  to  be  sequestrated  in  an  asylum,  but 
showing  many  of  the  characteristics  of  the  class.  When 
the  condition  is  so  far  advanced  as  to  require  asylum 
treatment,  there  are  generally  some  marked  delusions 
perceptible  at  least,  and  the  perversion  of  character  is 
such  that  it  is  impossible,  as  a  rule,  for  the  patient  to 
be  endured  by  friends  or  relatives. 

A  rather  typical  case  of  this  kind  that  came  under 


HYSTERIC    INSANITY.  279 

our  care  illustrates  the  form  rather  better  than  any 
general  description.  She  was  a  woman  of  about  thirty, 
of  very  fair  physical  development,  unmarried,  of 
neurotic  heredity,  though  her  family  history  did  not, 
we  believe,  include  any  instances  of  actual  insanity. 
She  had  been,  a  number  of  years,  an  asylum  patient, 
and  was  considered  a  particularly  troublesome  one,  not 
on  account  of  violence,  but  because  of  her  peculiarly 
captious  and  discontented  ways  and  constant  demands 
for  special  care  and  attention.  Her  general  bodily 
health  and  nutrition  were  fair,  but  she  had  constant 
ailments  to  complain  of,  was  persistent  in  her  demands 
for  hypnotics  of  one  kind  or  another,  and  came  nearer 
to  being  a  chloral  habitue  than  any  patient  in  the 
asylum.  As  she  was  not  at  all  inclined  to  run  away, 
she  was  allowed  her  liberty  about  the  grounds,  but 
demanded  the  privilege  of  visiting  the  wards  other  than 
the  one  she  was  in,  and  was  permitted  by  the  super- 
intendent, for  the  sake  of  peace,  to  have  a  key  to  her 
ward.  With  this  she  went  about  as  she  pleased,  and 
professed  to  direct  the  work  of  certain  rather  demented 
patients  who  submitted  themselves  to  her  direction. 
This  unusual  privilege  did  not  satisfy  her,  however, 
but  every  day  she  came  to  the  superintendent  with  her 
grievances  and  demands,  stopping  him  wherever  she 
met  him  and  holding  him  in  conversation  as  long  as 
possible.  If  anything  went  wrong,  if  her  demands 
were  not  satisfied,  she  would  refuse  to  eat,  or  sit  around 
"like  patience  on  a  monument"  in  some  conspicuous 
position  where  she  thought  her  ostentatious  grief  could 
attract  attention.  At  times  she  could  go  for  days 
apparently  without  eating,  but  it  was  never  thought 
necessary  to  forcibly  feed  her,  as  she  always  came 
to  her  meals  again,  and  it  was  thought,  at  times  at 
least,  she  ate  secretly  from  stores  she  had  managed  to 
obtain  in  some  way  or  other.  She  threatened  suicide 
at  times,  but  was   never  taken   seriously,  and  unless 


20O  INSANITIES    OF    THE    NEUROSES. 

her  death  was  suicidal,  which  was  not  suspected,  she 
never  really  made  any  attempts.  The  erotic  element 
was  not  prominent  in  her  case,  but  she  was,  in  her  way, 
exceedingly  religious,  though  her  conduct  was  very 
inconsistent  with  her  pretension.  She  would  get 
together  a  half  a  dozen  almost  totally  demented 
patients  and  have  a  prayer-meeting,  she  taking  all  the 
active  parts,  and  sometimes  was,  it  is  said,  exceedingly 
personal  in  her  prayers  in  remarks  about  those  whom 
she  deemed  were  worrying  or  abusing  her.  Typical 
hysteric  attacks,  convulsions,  etc.,  were  not  frequent, 
if  they  occurred;  but  modified  hysteric  phenomena, 
such  as  apparent  trance  states,  etc.,  occurred  at  times, 
and  there  was  a  very  decidedly  marked  tinge  of  hysteria 
in  nearly  all  her  actions.  It  is  probable  that  many  of 
the  complaints  she  made  represented  feelings  that  were 
real  to  her,  but  in  almost  all  voluntary  acts  there  was 
the  usual  apparent  self-consciousness  and  striving  for 
effect  that  is  common  in  these  hysteric  patients.  The 
moral  deterioration  of  reasoning  mania  was  here 
peculiarly  hysteric  in  its  manifestations  of  calumnious 
charges,  complaints  of  abuse,  etc. 

Many  of  the  cases  of  blackmail  and  false  accusations 
against  physicians  may  be  credited  to  this  form  of 
hysteric  derangement  in  females,  and  we  have  known 
one  or  two  striking  instances  of  the  kind.  One,  a 
young  woman  well  connected,  but  cut  loose  from  her 
family  and  rather  repudiated  by  her  relatives,  used  to 
frequent  doctors'  offices  and  have  hysteric  attacks 
there,  and  in  one  or  two  cases,  at  least,  attempted  to 
get  up  compromising  situations,  and  once  succeeded 
so  far  as  to  give  considerable  mental  uneasiness  for  a 
time  to  a  rather  prominent  physician.  There  are  cases 
on  record  where  still  more  serious  consequences  have 
resulted ;  men  have  been  convicted  of  crimes  of  which 
they  were  innocent  on  false  testimony  of  hysteric 
women. 


HYSTERIC    INSANITY.  251 

While  this  special  form  of  mental  disorder  is  by  far 
most  frequent  in  the  female  sex,  it  is  not  unknown  in 
males ;  of  course,  in  these  cases  the  symptoms  are  some- 
what modified,  but  it  occurs  only  in  men  with  somewhat 
abnormal  and  feminine  mental  organizations.  In  some 
of  these,  sexual  perversion  is  a  notable  symptom,  and  it 
seems  probable  that  this  hysteria  is  at  the  bottom  of 
many  cases  of  this  abnormality.  In  male  hysteric  insan- 
ity we  see  many  of  the  same  tendencies  to  morbid  emo- 
tionalism, eroticism,  false  accusations,  the  exaggerated 
suggestibility,  certain  kinds  of  delusive  conceptions, 
occasional  threats  or  apparent  attempts  at  self -in  jury 
or  suicide,  refusal  of  food,  etc.,  that  we  observe  in  the 
female,  but  actual  hysteric  convulsive  attacks  are  very 
rare,  and  the  well-marked  hysteric  physical  stigmata 
are  also  uncommon.  Male  hysteric  insane  are  more 
likely  to  be  suicidal  or  homicidal  than  are  the  females. 

Something  may  be  said  here  in  regard  to  traumatic 
hysteria,  which  sometimes  amounts  to  a  kind  of  in- 
sanity, showing  itself  in  an  exaggerated  valuation  of 
physical  disabilities  and  a  certain  moral  weakening 
that  leads  the  individual  to  overact  and  sometimes 
simulate.  There  are  probably  sometimes  actual  hal- 
lucinations and  certainly  delusive  conceptions.  These 
cases  may  be  regarded  as  rare,  though  hysteria  from 
this  cause  is  common.  They  have  chiefly  a  forensic 
importance. 

The  diagnosis  of  hysteric  insanity  is  generally  easy; 
the  earmarks  of  hysteria  are  too  evident  to  be  con- 
cealed. The  hysteric  attack  itself  and  the  subsequent 
or  associated  mental  disturbances  have  a  certain  re- 
semblance to  epilepsy,  but  the  distinction  between 
them  is  generally  easy,  at  least  if  closely  and  con- 
tinuously observed.  There  is  seldom  or  never  the 
purposeless  violence  of  the  epileptic,  and  while  absolute 
unconsciousness  is  not  so  invariable  in  epilepsy  as  has 
been  commonly  stated,  it  is  sufficiently  the  rule  to 


252  INSANITIES    OF    THE    NEUROSES. 

serve  as  a  diagnostic  sign  in  most  cases.  There  is  a 
wide  difference  between  even  the  acute  maniacal  type 
of  hysteric  mental  disorder  and  that  of  epilepsy.  It 
must  be  remembered,  however,  that  hysteria  is  to  a 
certain  extent  a  frequent  complication  of  epilepsy,  and 
this  may  sometimes  lead  to  some  uncertainty  as  regards 
special  symptoms  and  particular  attacks.  In  such 
cases,  where  doubt  is  serious  it  is  more  probable  that 
we  may  have  hysteria  complicating  epilepsy  than  the 
reverse  condition.  The  diagnosis  from  adolescent  in- 
sanity will  be  noticed  when  considering  that  type  of 
derangement. 

The  prognosis  of  the  acute  attacks,  in  themselves,  of 
hysteric  insanity  is  generally  favorable,  but  they  are 
not  a  good  sign  as  regards  the  outcome  of  the  general 
condition.  Considering  the  disorder  as  largely  a 
degenerative  psychosis,  we  cannot  say  that  the  pros- 
pects of  complete  and  permanent  recovery  are  the  most 
hopeful.  As  regards  hysteric  reasoning  mania,  its 
prognosis  is  distinctly  bad,  and  its  tendency  is  ulti- 
mately toward  dementia. 

The  development  of  the  insanity  is  sometimes  due  to 
anemia  or  an  auto-intoxication,  or  both  combined,  and 
the  early  recognition  of  these  pathologic  conditions  and 
their  correction  may  result  in  recovery.  The  treat- 
ment for  this  purpose  should  be  mildly  alterative,  tonic, 
and  laxative ;  as  an  alterative,  the  auri  et  sodii  chlor- 
idum  gr.  -^  (0.006),  with  pulv.  resina  guaiacse  gr.  iv 
(0.25),  one  hour  before  meals;  and  as  a  tonic,  ferri  sul- 
phas gr.  ij  (0.13),  sodii  carbonas  gr.  ij  (0.13),  ext.  nucis 
vomicae  gr.  ^  (0.0012),  sodii  arsenas  gr.  -^  (0.003),  after 
meals;  as  a  laxative,  ext.  aloes  gr.  3  (0.06),  pulv.  ipecac, 
gr.  yL  (0.006),  ext.  hyoscyami  gr.  j  (0.06). 

These  patients  at  the  beginning  of  the  acute  attacks 
should  be  put  to  bed  and  given  daily  massage  and 
faradic  electricity,  and  from  time  to  time  colonic  flush- 
ings.    The  menses  usually  stop,  and  this  is  a  cause  of 


HYSTERIC    INSANITY.  283 

much  disturbance  of  anxious  mothers,  under  the  mis- 
taken notion  that  this  failure  is  the  sole  pathology,  and 
they  often  demand  earnest  measures  directed  to  this 
function.  The  suppression  of  the  menses  is  not  the 
cause  of  the  insanity,  but  the  result,  and  so  soon  as 
reason  is  restored  menstruation  will  resume;  and  all 
local  treatment,  unless  there  is  positive  evidence  of 
disease,  should  be  avoided,  because  it  will  not  benefit 
but  usually  will  aggravate  the  case.  These  cases,  as 
already  stated,  have  much  sexual  erethism,  and  the 
manipulation  of  the  organs,  while  it  may  give  them 
pleasure  for  the  time  being,  only  exaggerates  the  dis- 
turbance then  present. 

Cases  of  hysteric  insanity  are  best  treated  in  a 
hospital  or  sanitarium ;  the  removal  from  old  influences, 
the  judicious  control  and  oversight,  are  essential.  The 
hopeless  cases  of  reasoning  mania,  with  some  progress 
toward  dementia,  can  be  better  managed  in  an  institu- 
tion, and  outside  they  are  very  inconvenient  and  some- 
times dangerous  members  of  society.  The  possibility 
of  suicide  is  a  serious  matter  for  consideration  in  a  few 
of  these  cases,  and  there  is  in  all  a  danger  of  trouble 
from  the  uncontrolled  impulses  to  outre  or  vicious 
actions.  Moral  treatment  is  not  always  very  success- 
ful, but  it  is  always  important ;  these  patients  should  be 
managed  kindly  but  firmly,  and  it  is  often  disastrous 
when  conduct  toward  them  that  too  much  humors 
or  in  any  way  encourages  their  marked  desire  for 
sympathy  or  attention  is  adopted.  Regular  useful 
employment  is  one  of  the  first  things  to  be  insured 
where  possible.  The  suggestibility  of  these  patients, 
if  it  can  be  properly  utilized,  may  be  a  valuable  aid  in 
the  treatment,  and  the  good  effects  of  many  remedial 
agents,  such  as  electricity,  hydrotherapy,  etc.,  can  be 
greatly  enhanced  in  this  way.  There  are  few  mental 
disorders  where  so  much  depends  upon  the  tact  and 
good  judgment  of  the  physician  as  in  this. 


284  INSANITIES    OF   THE    NEUROSES. 

OTHER  FORMS  OF  NEUROTIC  INSANITY. 

There  are  still  one  or  two  forms  of  mental  disorder 
associated  with  or  dependent  upon  general  conditions 
or  neuroses  that  deserve  mention,  though  possibly  not 
a  place  in  the  classification  as  distinct  species.  Neu- 
rasthenia is  one  of  these  general  conditions  that  has 
given  its  name  to  forms  of  mental  disorder,  but  this 
falls  generally,  in  our  opinion,  better  under  the  head 
of  exhaustion  or  toxic  insanity.  It  is  also  used  some- 
times as  an  adjective  prefix  to  certain  borderland  condi- 
tions dependent  upon  original  structural  and  functional 
nervous  defects,  which  will  be  noticed  more  fully  else- 
where. Choreic  insanity  is  another  type  often  included 
here,  and  the  mental  derangement  is  so  clearly  associ- 
ated with,  if  not  produced  by,  the  disorder  that  the  term 
is  to  a  certain  extent  justified.  Chorea  is,  as  Berkeley 
and  others  have  shown,  in  all  probability  dependent 
upon  an  infection  attacking  the  cerebral  and  spinal 
gray  matter,  and  it  is  not  at  all  improbable  that  this 
process  involving  the  cerebral  cortex  may  affect  intel- 
lection as  well  as  the  motor  function.  While  it  is 
possibly  not  infrequent  to  have  a  slight  mental  impair- 
ment in  chorea,  actual  insanity  is  rare,  and  is  met  with 
only  in  the  severe  cases,  probably  in  not  more  than  0.5 
to  1%  of  the  total,  and  then  only  when  the  insane 
predisposition  happens  to  exist  in  the  heredity.  The 
so-called  chorea  major,  however,  is  a  sort  of  choreic 
hysteria,  that,  while  a  pronounced  psychosis,  need  not 
be  here  considered. 

Apart  from  its  direct  association  with  the  neurosis, 
choreic  insanity  is  not  specially  characteristic  in  its 
symptoms ;  its  manifestations  may  take  on  almost  any 
of  the  types  met  with  in  the  forms  of  mental  disease. 
There  may  be,  and  very  frequently  is,  a  confusional 
hallucinatory  delirium ;  indeed,  this  is  one  of  the  com- 
mon types.     In  extreme  cases  we  may  have  stupor  of 


OTHER    FORMS    OF    NEUROTIC    INSANITY.  285 

a  very  marked  type.  In  the  form  called  chorea  in- 
saniens,  or  at  least  in  the  most  typical  cases,  the 
mental  derangement  is  a  sort  of  acute  delirium,  with 
high  temperature,  that  may  terminate  fatally  in  a  few 
days  or  may  moderate  and  end  either  in  recovery  or  a 
more  or  less  permanent  dementia,  or  in  some  other 
insane  type  lasting  for  weeks  or  months  and  even  years. 
Delusions  and  a  paranoiac  state  may  sometimes  occur 
in  chorea,  and  the  delusions  or  hallucinations  are  rather 
more  likely  than  not  to  be  of  a  terrifying  character. 
Melancholia  is  not  so  frequent  as  mania-like  conditions, 
but  the  depression  is  apt  to  be  extreme,  and  the  suicidal 
tendency  marked.  The  diagnosis  is  usually  easy  if  the 
chorea  is  recognized,  but  it  is  not  improbable  that  some 
cases  of  chorea  have  been  overlooked  in  asylums,  the 
motor  symptoms  having  been  masked  by  those  of 
agitated  melancholia  or  acute  maniacal  confusion  or  of 
mania.  This  can  happen,  of  course,  only  when  the 
observer  has  been  very  superficial  or  the  motor  symp- 
toms have  nearly  disappeared.  After  the  choreic  sym- 
toms  have  disappeared  there  is  nothing  to  particularly 
denote  the  origin  of  the  derangement,  unless  there  be 
present  the  jerky  inconstant  character  of  the  delirium 
claimed  by  Clouston  to  exist  in  these  cases. 

The  prognosis  of  the  insanity  of  chorea  is  variable. 
It  is  fairly  good  in  the  mild  cases  or  those  in  which 
there  is  only  a  moderate  mental  impairment  or  mild 
loquacious  mania;  in  such  the  mental  may  generally 
be  expected  to  subside  with  the  physical  symptoms. 
In  the  acutely  delirious  and  the  stuporous  ones,  on  the 
other  hand,  it  is  bad,  the  majority  failing  to  completely 
recover,  and  the  mortality  is  also  high  in  these,  espe- 
cially the  delirious  cases  with  excessive  temperature. 
A  guarded  opinion  should  be  given,  as  a  rule,  in  pro- 
nounced cases  of  maniacal  or  melancholic  insanity  with 
chorea. 

The  treatment  of  these  cases  of  insanity  demands 


286  INSANITIES    OF    THE    NEUROSES. 

absolute  rest  in  bed,  relief  of  the  distressing  insomnia, 
tonics, — especially  arsenic,  a  drug  that  has  a  more  speci- 
fic influence  over  chorea  than  any  other, — and  judicious 
feeding.  If  the  condition  of  the  circulation  will  admit 
of  it,  chloral  is  the  best  sleep-producing  remedy,  and 
when  the  circulation  is  too  feeble  to  warrant  its  use 
alone,  tincture  of  hyoscyamus  may  be  combined  with 
it.  These  cases  are  often  benefited  by  the  use  of 
alcoholic  stimulants;  the  anesthetic  and  force-giving 
qualities  of  the  drug  have  been  of  service.  Port  wine, 
freely  used,  is  of  signal  service.  To  secure  the  specific 
effect  of  arsenic  it  should  be  given  in  gradually  increas- 
ing doses  to  its  fullest  physiologic  effect ;  quinin,  iron, 
and  strychnin  are  also  usually  indicated. 

Hypochondria  is  a  symptom  that  may  occur,  and 
even  be  the  apparently  predominant  feature  of  certain 
stages,  in  more  than  one  well-defined  species  of  insanity, 
so  that  its  existence  alone,  or  its  prominence  even, 
would  not  justify  the  recognition  of  a  special  hypo- 
chondriacal type  or  species  in  every  case.  It  may  be 
the  dominating  note  in  the  delusions  of  the  early  stages 
of  paresis,  or  the  first  phase  of  typical  systematized 
paranoia.  In  fact,  it  is  almost  the  rule  in  the  latter,  at 
least  to  a  certain  extent,  though  it  is  not  always  prom- 
inent as  such ;  the  introspection  may  take  only  a  partial 
bend  in  that  direction.  It  is  not  unknown  in  some 
forms  of  melancholia,  especially  in  the  aged,  and  it  is 
often  an  early  symptom  of  senile  derangement. 

Aside  from  these  conditions,  however,  there  are  cer- 
tain cases  that  can  be  best  classed  as  specially  hypo- 
chondriacal, and  that  do  not  develop  into  or  occur  in 
the  course  of  other  definite  types  of  mental  disorder, 
which  can,  therefore,  be  best  classed  as  a  type  by 
themselves,  a  true  hypochondriacal  insanity.  These 
are  recognized  as  such  by  certain  of  the  Italian  school, 
while  others,  French,  German,  or  American,  have  of 
late  years  been  inclined  to  reject  their  specific  rank. 


HYPOCHONDRIACAL    INSANITY.  287 

The  patients  of  this  class  are  usually  markedly  degen- 
erates. 

Hypochondriacal  Insanity. — The  basis  of  this  form 
of  insanity  is  hypochondriasis — a  true  neurosis  closely 
allied  to  hysteria  and  neurasthenia  and  close  to  in- 
sanity. 

The  essential  characteristic  of  the  neurosis  is  per- 
version of  the  organic  sensations  and  persistent  intro- 
spection. The  various  organs  of  the  body  often  pre- 
sent an  activity  of  which,  in  a  state  of  health,  we  would 
be  unconscious,  but  become  to  these  unfortunate 
people  painfully  conscious,  and  their  whole  being  is 
given  to  the  contemplation  of  the  sensation,  and  in 
conjuring  up  the  most  serious  possible  pathologic  con- 
ditions. Thus,  an  abnormal  sensation  in  the  stomach 
becomes  in  their  active  imaginations  a  cancer;  a  dis- 
comfort in  the  lungs  or  heart  becomes  tuberculosis  or 
valvular  disease.  Much  of  introspection  circles  around 
the  sexual  system,  and  perfectly  normal  seminal  emis- 
sions become  most  serious  and  dangerous  symptoms 
of  disease.  One  patient  could  not  eat  because  the 
stomach  and  intestine  had  been  passed  at  stool; 
another  could  not  be  induced  to  make  any  exertion 
because  the  lungs  had  been  coughed  up  years  before. 
The  diagnosis  must  be  based  on  the  history.  The 
prognosis  is  unfavorable  as  to  cure  except  in  the  few 
cases  in  which  the  hypochondriasis  develops  at  the 
climacteric  period.  The  prognosis  as  to  life  is  good; 
the  writer  had  one  of  these  patients  under  observation 
for  nearly  twenty-three  years,  and  then  she  died  of  a 
pneumonia  following  la  grippe  infection.  This  pa- 
tient's perversion  centered  around  her  stomach  and 
uterine  system ;  no  meal  was  eaten  without  an  elaborate 
argument  as  to  the  food  that  should  be  taken,  and 
after  the  decision  was  made  serious  apprehension  arose 
as  to  beneficial  effects  that  might  follow.  Every  men- 
strual period  was  a  serious  time,  although  the  function 


2  55  INSANITIES    OF    THE    NEUROSES. 

was  normal;  there  was  the  greatest  apprehension  of 
hemorrhage  or  obstruction.  One  doctor  after  another 
is  consulted  in  such  cases  until  finally  one  is  found,  it 
may  be  with  quackish  proclivities,  who  agrees  with 
the  patient  and  doses  with  drugs,  thereby  fixing  and 
exaggerating  the  illusions  and  delusions. 

This  disposition  to  inquire  into  organic  sensations 
and  exaggerate  them  in  introspection  begins  often 
early  in  life  and  grows  with  the  growth  of  the  individual, 
until  finally  the  whole  life-work  is  occupied  in  the 
painful  contemplation  of  these  visceral  conditions. 
Hypochondriasis  is  much  more  common  among  men 
than  women. 

The  symptoms  of  these  become  more  and  more  ex- 
aggerated, until  there  can  be  no  question  of  their  in- 
sanity, and  of  their  irresponsibility.  They  frequently 
lose  their  identity  in  whole  or  in  part;  personality  is 
based  in  part  upon  cenesthesis,  and  the  perversion  of 
this  leads  to  its  disorder.  This  loss  of  personal  identity 
may  be  complete ;  one  of  these  patients  imagined  that 
his  body  was  dead  and  that  his  ego  had  taken  possession 
of  another;  finally  the  doctors  were  summoned  and  a 
trained  nurse  was  usually  in  attendance. 

The  treatment  in  the  ordinary  cases  consists  simply 
in  meeting  symptoms  as  they  arise  and  in  making  the 
patient  comfortable  in  various  ways  by  anodynes  and 
by  suggestions. 

The  cases  that  develop  at  the  climacteric  can  often 
be  benefited  by  attention  to  elimination,  often  so 
deficient  at  this  period  of  life ;  and  by  such  tonics  and 
alteratives  as  will  improve  the  general  condition,  by 
rest,  massage,  faradism,  and  later  by  judicious  exer- 
cise and  occupation. 


CHAPTER  XVI. 
INSANITIES  OF  CRITICAL  PERIODS. 

By  the  insanities  of  critical  periods  we  here  under- 
stand those  mental  disorders  directly  connected  with 
special  periods  of  development  or  of  the  appearance 
and  disappearance  of  important  functions.  Not  all 
critical  periods  are  associated  with  insanity,  properly 
so  called,  that  is  characteristic  in  any  way,  or  that  calls 
for  special  notice  here.  Thus  the  second  dentition, 
the  passage  from  infancy  to  childhood,  is  a  very  im- 
portant period  of  human  development,  but  no  author 
has  yet  attempted  to  include  a  special  type  of  the  in- 
sanities of  this  period.  Nevertheless,  it  is  at  this 
special  time  many  of  the  permanent  degenerative 
stigmata  begin  to  appear,  and  changes  undoubtedly 
occur  that  lead  later,  in  many  cases,  to  profound 
physical  and  even  mental  defects.  They  are  not,  how- 
ever, prominently  noticeable  at  this  particular  age,  and 
we  therefore  have  no  insanity  of  dentition  even  among 
the  more  elaborate  etiologic  classifications.  The  men- 
tal development  at  this  period  is  undisturbed,  and 
while  brain  changes  certainly  occur,  they  are  not  such 
as  to  affect  the  individual's  mental  health  at  the  time. 

It  is  different  at  the  next  great  critical  period,  that 
of  puberty  and  adolescence.  Here  the  system  has  to 
accommodate  itself  to  new  functions  and  relations,  and 
an  entirely  new  range  of  mental  activities  is  opened  up. 
The  imagination,  the  emotions,  as  well  as  the  intellect, 
are  stimulated  and  widened  in  their  scope,  the  indi- 
vidual becomes,  at  it  were,  a  new  person,  responsi- 
bilities are  increased,  and  the  intellect  taxed  as  never 
before.  In  this  stage  of  life,  which  really  covers  many 
19  289 


290  INSANITIES    OF    CRITICAL    PERIODS. 

years,  from  the  early  awakenings  of  the  sexual  instinct 
to  fully  developed  physical  maturity,  mental  break- 
down is  a  possibility  and  frequently  also  a  realized 
fact.  This  is  the  chief  critical  period  of  human  ex- 
istence as  far  as  the  risk  of  mental  derangement  is 
concerned. 

The  climacteric,  or  change  of  life,  when  the  repro- 
ductive activities  cease,  is  usually  also  reckoned  as  a 
time  when  there  is  special  liability  to  mental  break- 
down, and  climacteric  insanity  in  women  has  a  place  in 
nearly  all  our  etiologic  classifications  of  mental  disease. 
This  change  is,  however,  in  our  opinion  much  more 
generally  a  physiologic  one  than  is  that  of  the  instal- 
ment of  this  function,  and  should,  therefore,  be  less 
likely  to  be  attended  with  so  serious  a  derangement  as 
insanity.  In  perfectly  normal  individuals  this  change 
ought  to  occur  without  disturbance,  but  such  are  rare, 
and  there  is  very  frequently,  in  the  readjustment  of  the 
physical  functions,  a  disturbance  of  the  mental  opera- 
tions that  in  extreme  cases  or  in  those  predisposed 
extends  to  actual  mental  disease.  We  cannot  here, 
however,  as  in  the  case  of  insanity  of  adolescence, 
point  out  special  characteristics  of  the  mental  derange- 
ment of  this  period  that  are  so  constant  and  recogniz- 
able as  to  give  us  a  well-defined  species.  Climacteric 
insanity  has,  therefore,  only  an  etiologic  reason  for  its 
distinction,  and  our  notice  of  it  will,  therefore,  be  more 
general  and  brief  than  that  of  the  other  types  to  be 
described  as  appertaining  to  critical  periods. 

Lastly  we  have  the  period  of  the  decline  of  life,  with 
its  attendant  physical  and  mental  decay  and  failure. 
Here  we  have  mental  disorders  of  various  types,  but  so 
related  by  their  common  causation  that  we  can  often 
recognize  them  as  characteristic.  Senile  insanity,  or 
rather  senile  insanities,  have,  therefore,  a  recognized 
place  in  our  classification. 


ADOLESCENT    INSANITY.  291 


ADOLESCENT  INSANITY  (DEMENTIA  PRAECOX, 
HEBEPHRENIA). 

The  term  adolescent  insanity,  as  here  used,  covers  a 
rather  wide  range  of  mental  disorders  which  have  been 
described  by  authorities  under  various  names, — pubes- 
cent insanity,  dementia  prascox,  hebephrenia,  cata- 
tonia, etc., — which  all  seem  to  us  best  included  under 
one  general  head.  The  term  adolescent  is  chosen  as 
probably  the  best  one  to  designate  its  general  character, 
though  in  this  it  is  not  exact,  as  its  incidence  in  time 
covers  the  whole  period  from  puberty  to  early  adult 
life.  It  is  preeminently  the  insanity  of  development, 
or  rather  of  its  disorders;  its  dominant  characteristic 
is  the  tendency  to  dementia,  and  it  is  on  this  that  its 
definition  must  be  based.  Adolescent  insanity  is  a 
group  of  morbid  mental  symptoms  occurring  at  about 
the  period  of  sexual  development,  with,  in  general,  a 
somewhat  characteristic  affective  type,  tending  to 
ultimate  dementia  with  a  more  or  less  rapid  course. 
Including,  as  we  do  here,  not  only  the  ordinary  type 
of  pubescent  insanity,  but  also  catatonia  and  some 
forms  marked  by  delusional  symptoms,  a  more  close 
and  accurate  definition  is  not  practicable.  It  is  a 
species  better  described  than  defined,  but  one  that 
exists  and  is  familiar  to  the  practical  alienist. 

It  should  be  said  here  that  there  are  sometimes  con- 
sidered under  this  head  a  number  of  borderland  condi- 
tions that  occur  more  or  less  frequently  during  the 
period  of  sexual  development,  but  which  we  exclude, 
believing  them  to  belong  more  properly  elsewhere. 
Besides  a  common  sort  of  pseudo-melancholia,  some 
forms  of  sexual  hypochondria  and  neurasthenia  are  to 
be  reckoned  among  these,  though  the  former  is  some- 
times hardly  anything  more  than  a  worrying  about 
sexual  matters  due  to  misinformation  and  terrifying 
statements    of    quacks.     True    adolescent    insanity  is 


292  INSANITIES    OF    CRITICAL    PERIODS. 

preeminently  a  degenerative  psychosis ;  these  forms  are 
not  at  all  essentially  connected  with  any  real  degen- 
eracy inherited  or  acquired.  The  same  may  be  said 
of  some  conditions  due  directly  or  indirectly  to  sexual 
bad  habits  or  vice;  they  only  require  the  cessation  of 
their  cause  to  insure  their  disappearance.  Insanity 
from  masturbation  may  occur,  but  it  is  generally  in 
predisposed  individuals,  and  the  vice  only  an  exciting 
cause,  when  it  is  not,  on  the  contrary,  simply  an  effect 
or  symptom  of  the  disease. 

The  form  of  derangement  elsewhere  described  under 
the  name  of  original  paranoia,  in  connection  with  other 
paranoias  or  delusional  insanities,  has  some  apparent 
claim  to  be  considered  here.  Appearing,  as  it  does, 
during  this  period  of  developmental  stress,  and  being 
also  a  peculiarly  degenerative  type,  it  might  seem  that 
it  could  also  be  properly  reckoned  as  belonging  to  this 
group  of  adolescent  derangements.  Its  nature  and 
cause,  however,  are  different;  while  its  subjects  are 
markedly  defective,  bordering  even  in  some  respects  on 
imbecility,  the  condition  is  not  a  rapidly  progressive 
one,  if  progressive  at  all,  and  its  symptoms  are  widely 
different  from  those  of  the  forms  here  under  con- 
sideration. 

It  should  also  be  noted  here  that  not  every  case  of 
mental  derangement  occurring  between  puberty  and 
the  twenty-fifth  or  thirtieth  year  is  one  of  adolescent 
insanity.  While  this  period  has  its  own  types,  well 
marked  as  we  believe,  it  is  also  a  stage  of  life  in  which 
any  mental  weakness  is  liable  to  reveal  itself  in  other 
non-typical  ways.  Many  cases  of  recurrent  or  periodic 
insanity  make  their  first  appearance  about  this  time, 
hysteric  derangements  may  also  date  from  this  period, 
and  under  conditions  of  special  strain  the  confusional 
or  delirious  psychoses  may  occur.  Congenital  paretic 
dementia  may  and  generally  does  have  its  earliest  mani- 
festations about  or  near  the  age  of  puberty,  and,  in 


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Hebephrenia. 


ADOLESCENT  INSANITY.  293 

short,  almost  every  clinical  species  of  insanity  except 
senile  dementia  may  appear  during  these  ten  or  fifteen 
years.  They  may  even  be  colored  to  some  extent  by 
the  age  peculiarities,  but  they  are  not  therefore  neces- 
sarily adolescent  insanity.  The  type  with  all  its  varia- 
tions is  a  peculiar  one,  and  may  be  considered  as  a 
species  by  itself.  It  may  be  considered  as  a  special 
form  of  mental  breakdown  under  the  strain  of  sexual 
development  at  the  period  of  puberty  and  shortly 
after,  in  subjects  naturally  defective  and  predisposed. 
Other  forms  of  insanity  occurring  at  this  time  under 
the  same  conditions  of  stress  are  accidental,  but  in  the 
genuine  adolescent  insanity  the  failure  is  an  almost 
inevitable  consequence  of  the  inability  of  the  organism 
to  meet  the  special  demand.  Kraepelin  compares  it 
with  a  tree  that  has  sufficient  soil  for  its  growth  to  a 
certain  point,  and  that  when  this  is  exhausted  it  fails. 
The  comparison  is  not  an  inapt  one,  and  assists  in  the 
comprehension  of  the  actual  state  of  the  case  in  this 
disorder. 

From  what  has  been  said  above,  it  will  be  easily  seen 
that  the  etiology  of  adolescent  insanity  is  a  compara- 
tively simple  matter.  According  to  our  conception  of 
the  disease,  it  is  based  on  an  originally  defective  nerv- 
ous organization,  and  is  particularly  an  insanity  of  the 
degenerates.  This,  of  course,  applies  mainly  to  the 
fully  developed  form.  The  abortive  and  borderland 
conditions  are,  of  course,  not  here  included. 

Symptoms. — The  initial  symptoms  of  adolescent  in- 
sanity are  widely  different  in  different  cases.  There  is 
most  often,  however,  a  preliminary  depressed  stage, 
sometimes  hypochondriacal,  the  patient's  conscious- 
ness being  self-centered  on  imaginary  conditions  of 
disease.  In  others  these  are  self-accusatory  ten- 
dencies, as  in  melancholia,  and  in  still  others  per- 
secutory delusions;  they  feel  themselves  slighted  or 
overlooked,  and  dwell  moodily  on  their  lack  of  proper 


294  INSANITIES    OF    CRITILAL    PERIODS. 

estimation  and  the  slights  or  even  insults  they  have 
received.  Occasionally  there  are  decided  suicidal 
tendencies,  and  an  attempt  at  self-destruction  may  be 
the  first  thing  to  call  attention  to  their  mental  derange- 
ment. Sometimes  these  attempts  are  made  in  such  a 
way  as  to  show  a  foolish  and  apparently  half-hearted 
intention;  at  others  the  attempts  are  really  desperate 
and  sometimes  successful.  The  morbid  acts  may  take 
other  directions;  assaults,  arson,  and  even  homicide 
may  occur.  Again,  the  patient  often  sleeps  poorly,  is 
variable  in  appetite,  complains  of  headaches,  suffers 
often  from  constipation,  feels  dull  and  mentally  in- 
capable, tires  easily,  and  presents  other  signs  of  an 
apparent  aggravated  neurasthenia.  Or  there  may  be 
evidence  of  hallucinations,  and  active  delusions;  but 
very  frequently  the  insane  or  violent  acts,  such  as  those 
mentioned,  have  no  obvious  reason,  and  the  patient 
will  give  none.  In  some  there  is  an  obtrusive  religi- 
osity in  the  early  beginnings  of  the  disorder;  the  talk 
is  all  in  that  direction,  and  much  time  is  spent  in  read- 
ing the  Bible  or  religious  books.  The  most  character- 
istic feature  of  this  early,  generally  depressed  stage  is  a 
sort  of  childishness  or  weakness  of  thought  or  action, 
a  lack  of  good  judgment  corresponding  to  the  age,  and 
inability  to  correctly  estimate  conduct  even  in  the 
matters  where  it  would  seem  their  general  mental 
defect  ought  not  to  influence  them.  There  is  in  some 
of  these  cases  almost  from  the  first  a  marked  weakness 
involving  judgment  and  acts  before  the  intellect  has 
yet  become  so  noticeably  clouded  as  to  betray  their 
condition  in  other  ways.  A  foolish  emotionalism  is 
often  an  early  symptom,  laughing  and  crying  without 
adequate  cause  or  any  cause  at  all.  Again,  in  others 
an  offensive  and  silly  egotism  is  an  early  marked  symp- 
tom, and,  indeed,  this  is  sooner  or  later  prominent  in  a 
large  proportion  of  the  cases,  especially  in  males.  They 
swagger  and  show  a  tendency  to  assert  themselves  un- 


ADOLESCENT  INSANITY.  295 

duly,  are  impudent  to  their  elders,  and  inclined  to  defy 
authority.  Sometimes  they  show  decided  erotic  ten- 
dencies, and  masturbation  is  common.  A  silly  theat- 
rical manner  is  common  and  a  very  apparent  unduly 
exalted  notion  of  their  personality.  These  symptoms 
may  occur  before  marked  exalted  delusions  are  mani- 
fested, but  these  often  accompany  them,  and  are  occa- 
sionally very  prominent. 

In  other  cases  the  attack  may  begin  suddenly 
with  maniacal  excitement,  which  may  continue  for 
a  considerable  period  or  pass  into  a  sort  of  stuporous 
or  depressed  condition.  As  a  rule,  the  motor  excite- 
ment is  not  so  excessive  as  in  acute  mania,  and  it  may 
have  a  close  resemblance  to  the  agitated  form  of  con- 
fusional  insanity.  Sometimes  there  is  a  confusional 
dementia,  so  to  speak,  at  the  beginning,  the  most 
marked  phenomenon  being  mental  confusion,  which  is 
likely  to  soon  change  into  one  of  the  other  forms  men- 
tioned above.  In  fact,  there  is  almost  no  clinical  symp- 
tom of  incipient  insanity  that  may  not  be  reproduced 
in  the  early  stages  of  adolescent  insanity,  but  in  all  or 
nearly  all  cases  there  is  sooner  or  later  a  pronounced 
tinge  of  dementia  or  mental  weakness  apparent. 

As  the  case  progresses  the  mental  hebetude  becomes 
more  apparent,  though  there  may  be  remissions,  and 
even  apparent  return  to  the  normal  condition,  to  again 
relapse,  and  generally  the  second  stage  is  worse  than 
the  first.  There  is  sometimes  in  the  advancing  stages 
with  the  dementia  a  pronounced  anesthesia,  and  the 
patients  may  mutilate  themselves,  pull  out  their  hair, 
or  do  other  similar  acts,  which  are  also  observed  in 
other  forms  of  insanity,  but  in  our  experience  rather 
frequently  in  this.  Destructive  acts  are  common,  but, 
as  a  rule,  these  patients  are  not  violent  enough  to  be 
difficult  to  control.  These  acts  are  apt  to  be  utterly 
irrational,  as  are  often  also  their  answers  to  questions, 
though  these  latter  sometimes  appear  comically  con- 


296  INSANITIES    OF    CRITICAL    PERIODS. 

ceived.  A  young  woman  of  this  type,  who  could  not 
carry  on,  apparently,  a  connected  conversation  of  half 
a  dozen  sentences,  replied,  in  answer  to  the  question 
how  she  reached  the  asylum,  that  she  somehow  got 
aboard  the  cars,  and  as  she  had  on  a  plush  skirt  and 
the  seat  was  also  plush  she  was  unable  to  rise;  the 
supervisor  or  town  officer  who  accompanied  her,  she 
said,  was  a  stock-dealer,  and  therefore  found  it  in  his 
way  of  business  to  ship  her.  Another  patient,  a  young 
man,  one  night  pulled  out  nearly  every  hair  on  his  head 
and  body,  and  when  asked  why  he  did  it, ''said  he  wanted 
a  finger-nail  shave.  He  could  not  say  anything  more, 
apparently,  and  that  was  the  brightest  remark  he  ever 
made  in  the  advanced  stage  of  the  disease  then  existing. 
A  rather  characteristic  feature  of  many  cases,  before 
the  mental  weakness  has  become  too  pronounced,  is 
that,  with  the  varying  emotional  state,  changing  sud- 
denly from  depression  to  exhilaration,  and  vice  versa, 
these  patients  are  often  absolutely  indifferent  as  to 
their  condition,  even  when  still  capable  of  apparently 
appreciating  it ;  however  discontented  they  may  appear 
to  be  as  to  immediate  conditions,  they  do  not  worry 
about  their  future  or  the  prospects  of  their  disease. 
They  live  in  the  present  absolutely,  even  when  still 
retaining  to  a  considerable  extent  their  mental  faculties 
and  seemingly  recognizing  their  surroundings  and  the 
fact  of  their  being  considered  insane.  This  indifference 
is  also  noticeable  later,  when  their  minds  become 
apparently  more  clouded;  they  often  make  no  sign  of 
caring  for  their  comfort  or  whereabouts,  though  occa- 
sionally they  act  on  an  impulse  to  escape.  We  have 
known  an  apparently  rather  typical  case  of  this  form 
of  insanity  to  make  his  escape  unexpectedly  by  break- 
ing out  through  an  unguarded  window ;  he  was  found 
drowned  a  day  or  two  later,  presumably  a  suicide. 
There  is   an  uncertainty   about  this   special  type   of 


ADOLESCENT    INSANITY.  297 

dementia  as  to  acts,  etc.,  that  needs  the  special  watch- 
fulness of  whoever  has  the  care  of  its  subjects. 

Kraepelin  has  described  a  form  of  mental  disorder 
that  may  possibly  fall  into  this  general  class  of  adoles- 
cent dementias,  consisting  of  a  paranoiac  delusional 
derangement  of  rapid  course  terminating  in  a  demented 
confusional  condition.  It  begins,  according  to  his 
description,  with  restlessness,  headache,  emotional 
depression  passing  rapidly  into  a  delusional  state  with 
ideas  of  persecution.  Later,  or  early  in  some  cases, 
there  are  megalomaniac  ideas,  often  unsystematized, 
and  the  patient  falls  shortly  into  a  condition  of  con- 
fusional dementia  which  becomes  permanent.  The 
morbid  symptoms  have  in  some  cases  a  resemblance  to 
those  of  paresis,  but  the  course  and  outcome  are  dif- 
ferent and  the  physical  symptoms  are  wanting.  From 
its  special  course  and  the  fact  that  it  often  occurs  at  a 
more  advanced  age,  he  distinguishes  this  form  from 
adolescent  dementia,  while  recognizing  its  relations  to 
it.  We  have  not  recognized  this  type  as  clearly  shown 
in  cases  under  our  observation,  but  it  is  a  very  possible 
one,  and  is  mentioned  here  as  a  form  that  may  be  met 
with  in  practice.  It  is  certainly  not  frequent  in  the 
cases  of  insanity  met  with  by  us. 

Another  type  which  we  here  include  under  the  gen- 
eral head  of  the  insanity  of  adolescence  is  recognized 
by  a  large  number  of  authorities,  especially  among  the 
Germans,  as  a  distinct  species;  it  is  the  so-called  cata- 
tonia, or  insanity  of  muscular  tension.  This  form 
begins  usually  with  a  melancholic  stage,  much  as  in 
the  ordinary  type  already  described,  with  preliminary 
neurasthenic  symptoms,  headache,  insomnia,  etc., 
passing  gradually  into  a  more  or  less  acutely  depressed 
state,  with  sometimes  also  hallucinations  and  delusions 
of  a  depressing  or  terrifying  nature.  With  this,  there 
may  be  occasional  attacks  of  agitation,  and  even 
violence,  or  these  may  form  almost  the  earliest  phe- 


298  INSANITIES    OF    CRITICAL    PERIODS. 

nomena  of  the  disease.  Sooner  or  later,  sometimes 
after  maniacal  symptoms  have  appeared  or  before,  and 
oftener  perhaps  with  a  stupor  or  semi-stuporous  con- 
dition, the  special  symptom  of  this  type  makes  its 
appearance — a  muscular  stiffness  or  tension  varying  in 
degree  in  different  cases  from  merely  a  slight  rigidity, 
making  the  movements  stiff  and  somewhat  awkward, 
to  a  complete  waxy  flexibility  in  which  the  patient  is 
like  a  jointed  lay  figure  and  the  limbs  retain  any  posi- 
tion in  which  they  are  placed  till  gradually  by  the 
force  of  gravity  they  become  relaxed.  This  symptom 
is  not  altogether  peculiar  to  this  special  type  of  insanity ; 
it  may  rarely  appear  to  some  extent  in  stuporous  and 
melancholic  states,  but  in  no  other  is  it  so  constant  and 
manifest  as  in  this.  It  probably  indicates  a  peculiar 
irritation  of  the  motor  cortical  centers,  and  possibly 
also  a  morbid  derangement  of  the  inhibitory  apparatus. 
Another  symptom,  likewise  characteristic  of  this  type, 
and  also  indicating  special  irritability  of  a  cortical 
center,  is  that  which  has  been  named  "verbigeration." 
The  patient  talks  constantly  or  by  spells  without  regard 
to  sense,  the  sound  alone  guiding  his  remarks;  a  con- 
tinuous flow  of  words,  each  one  suggesting  another, 
and  more  usually  similar  in  sound  or  termination  and 
without  any  connection  otherwise  whatever.  In  ex- 
treme cases  one  or  two  words  or  phrases  or  a  few  mean- 
ingless syllables  will  be  repeated  over  and  over  again ; 
in  others,  a  short  sentence  may  be  consecutive,  and  be 
followed  by  another  rhyming  with  it  or  only  words  of 
similar  sound.  In  one  or  two  instances  where  the 
speech-centers  seemed  less  acutely  involved,  and  less 
out  of  relation  with  the  intellectual  functions  generally, 
we  have  observed  a  sort  of  rhyming  mania  in  which 
rather  striking  rhymes  were  occasionally  perpetrated. 

These  patients  in  their  stuporous  or  depressed  stages 
are  often  exceedingly  untidy;  they  pay  no  attention 
whatever  to  the  ordinary  calls  of  nature,  and  have  to 


ADOLESCENT  INSANITY.  299 

be  attended  to  in  every  detail.  Often,  too,  they  show 
a  complete  paralysis  of  the  appetite,  and  may  even 
resist  feeding,  so  that  artificial  feeding  has  to  be  re- 
sorted to.  Another  peculiarity  is  the  liability  in  these 
cases  to  sudden  spells  of  agitation  or  violence,  which 
subside  also  as  quickly.  With  these  depressed  or 
stuporous  stages  also  certain  body  symptoms  are 
noticed.  The  body-temperature  may  be  subnormal; 
Kraepelin  reports  seeing  it  as  low  as  3 3. 8°  C.  (9 2. 8° 
F.).  Their  limbs  are  cold  and  there  may  be  a  passive 
edema  of  the  lower  extremities ;  the  pulse  is  slow  and 
weak,  the  skin  harsh  and  dry,  or  there  may  be  at  times 
profuse  sweat  and  ptyalism.  The  thyroid  has  been 
reported  as  enlarged,  and  the  various  symptoms  of  dis- 
ordered nutrition  are  present,  the  general  sensibility 
appears  diminished,  the  skin  reflexes  weakened  or 
abolished,  while  the  deep  ones  may  be  increased. 

There  is  no  regular  order  in  the  stages,  according  to 
our  experience,  except  that  the  first  stage  is  apt  to  be 
one  of  depression  and  is  followed  by  the  phenomena  of 
muscular  tension  and  stupor,  etc.  Most  commonly 
there  is  a  melancholic  stage,  which  is  gradually  trans- 
formed into  a  brief  period  of  moderate  maniacal  ex- 
citement with  beginning  rigidity,  which,  as  the  stupor 
appears,  becomes  more  pronounced.  Later  there  may 
be  another  maniacal  stage  before  the  patient  passes 
into  the  final  dementia.  In  no  well-marked  case  ex- 
hibiting the  characteristic  symptoms  of  muscular  ten- 
sion and  verbigeration  have  we  observed  more  than  one 
complete  cycle  of  these  stages ;  in  all  there  was  either  a 
passage  directly  into  a  lasting  demented  condition,  or 
it  followed  a  brief  recurrence  of  mania  or  a  partial  re- 
mission and  repetition,  or  the  patient  was  carried  off  by 
some  intercurrent  disorder  before  it  was  fully  de- 
veloped. The  following  case  illustrates  this  type  in 
one  of  its  types  of  manifestation : 

B.  J.,  aged  twenty-one,  American,  of  German  parent- 


300  INSANITIES    OF    CRITICAL    PERIODS. 

age,  druggist  by  profession,  had  his  first  attack  of 
insanity  at  nineteen.  His  habits  as  to  alcohol,  etc., 
were  good,  but  he  was  said  to  have  been  a  masturbator 
for  some  time.  His  heredity  was  bad;  his  father  was 
insane  and  his  mother  was  hysterical.  On  admission 
to  the  hospital  he  appeared  to  be  thin  in  flesh ;  his  skin 
looked  unhealthy  and  the  perspiration  was  rather 
odorous;  his  movements  were  slow,  but  there  was  no 
visible  motor  defect.  Temperature  was  normal,  pulse 
80,  tongue  clean,  appetite  and  sleep  normal,  bowels 
rather  irregular.  There  was  no  apparent  local  disease. 
His  speech  was  slow,  and  when  asked  simple  questions, 
he  would  say  that  he  could  not  remember,  or  some- 
thing of  the  kind,  and  appeared  as  if  suspicious.  His 
general  expression  was  a  sort  of  half  stupid  smiling  one, 
but  his  actions  and  manners  showed  that  he  was  sus- 
picious as  to  the  examination  and  of  those  around  him. 
His  history  was  that  of  a  retiring,  abnormally  bashful 
youth,  of  good  habits  except  masturbation,  which  he 
admitted.  The  first  symptoms  observed  were  marked 
depression,  with  suspicion  of  his  friends  and  others, 
which  had  increased  up  to  the  time  of  his  commitment, 
though  the  depression  was  less  marked.  He  had  never 
acted  violently  and  was  considered  harmless ;  his  habits 
were  cleanly. 

It  was  evident  that  his  refusal  to  answer  questions 
was  partly  at  least  due  to  his  suspicious  disposition,  but 
there  was  also  some  slowness  of  intellection.  His  con- 
dition remained  unchanged  for  nearly  three  months, 
when  he  began  to  appear  brighter,  and  after  a  couple 
of  days  of  incoherent  noisy  excitement  he  became  more 
rational  and  natural  in  manner.  For  several  weeks 
this  improvement  continued,  and  finally,  except  for 
a  slight  degree  of  hardly  normal  exhilaration,  he  seemed 
perfectly  well,  talked  rationally,  wrote  letters  to  friends, 
etc. ;  then  he  passed  rather  suddenly  into  a  stuporous 
depressed  state,  and  his  whole  muscular  system  became 


ADOLESCENT  INSANITY.  301 

quite  rigid,  though  not  absolutely  so.  While  this  still 
lasted  his  mental  condition  passed  into  an  agitated 
melancholia,  in  which  he  would  throw  himself  down  on 
his  knees  and  cry  and  pray  for  considerable  periods  of 
time.  This  stage  passed  off  in  about  a  month  into  a  vio- 
lently maniacal  condition  in  which  he  became  very  noisy 
and  profane,  was  sleepless,  and  part  of  the  time  refused 
food,  though  forced  feeding  had  not  to  be  employed. 
His  appetite  then  became  very  irregular  for  a  short 
time,  when  he  began  to  eat  and  sleep  well,  though  still 
excited.  The  muscular  rigidity  still  showed  itself  in  a 
sort  of  stiffness  and  awkwardness  of  movement  and  the 
symptoms  of  verbigeration  became  quite  marked;  he 
repeated  strings  of  German  words  of  similar  or  sug- 
gested sound.  There  was  absolutely  no  sense  in  his 
monologue,  so  far  as  it  could  be  made  out,  and  some  of 
it  was  apparently  only  articulated  sounds  mixed  with 
repetitions  of  German  and  occasionally  English  words. 
This  condition  lasted  for  many  months,  during  which 
his  bodily  functions  were  carried  on  normally  and  he 
gained  in  weight  and  apparent  physical  health.  It 
then  graduated  into  a  state  of  noisy  dementia  with 
occasional  spells  of  destructiveness  and  untidy  habits, 
and  ended  finally  in  a  condition  of  nearly  complete 
dementia  without  stupor,  but  never  speaking  coher- 
ently and  only  occasionally  whistling  or  gesturing  to 
indicate  that  he  had  any  special  mental  activity  what- 
ever. No  special  change  occurred  after  this  as  long  as 
he  was  under  observation,  a  period  of  five  or  six  years. 
Another  patient,  a  female,  whose  insanity  was  first 
diagnosed  as  mild  melancholia,  developed  strong  nym- 
phomaniac tendencies  with  the  oncoming  of  a  maniacal 
phase  of  her  disorder,  and  from  this  passed  into  a  con- 
dition of  rigidity  so  pronounced  that  for  nearly  two 
years  she  could  be  put  into  almost  any  position  and 
her  limbs  would  retain  the  attitude  given  them  until, 
after  twenty  minutes  or  more,  they  were  brought  down 


302  INSANITIES    OF    CRITICAL    PERIODS. 

by  the  force  of  gravitation.  For  the  greater  part  of 
this  time  it  was  necessary  to  feed  her  mechanically. 
The  verbigeration  symptom  in  this  case  was  replaced 
by  a  rhyming  tendency,  nearly  everything  she  said 
being  in  rhyme  and  not  altogether  incoherent.  When 
asked,  for  example,  how  she  felt,  she  would  say, 
' '  Misery  and  grief  and  me  cannot  get  relief  " ;  or  how 
she  was  treated,  she  would  answer,  "  Don't  get  enough 
to  eat  and  they  keeps  me  whipt  and  beat,"  or  some- 
thing else  similarly  expressed  in  rhyme.  This  symptom 
was  marked  for  a  short  time  only,  just  before  passing 
into  the  rigid  stuporous  condition,  which  was  more 
marked  and  lasting  in  this  patient  than  in  any  other 
under  our  observation.  It  is  not  the  rule,  according  to 
our  observation,  for  the  changes  in  this  catatonic  in- 
sanity to  progress  through  more  than  one  cycle,  but  in 
this  case  it  appeared  as  if  the  patient  was  going  to 
repeat  her  earlier  experience.  Before,  however,  she 
reached  a  second  stage  of  stupor  with  rigidity  she  was 
carried  off  by  an  intercurrent  disorder. 

Remissions  may  occur  in  this  form  of  derangement, 
but  they  are  not  so  frequent  as  in  some  other  forms  of 
insanity,  and  have  generally,  in  our  cases,  been  rather 
short,  usually  of  only  a  few  days'  duration  at  most. 
They  occur,  of  course,  only  in  the  earlier  stages  of  the 
disorder,  and  are  absent  when  the  dementia  has  become 
pronounced.  An  apparent  cure  may  occur  in  the 
milder  cases,  but  it  seems  doubtful  whether  any  real 
recovery  without  decided  mental  defect  ever  occurs  in 
this  or  in  the  other  type  of  adolescent  insanity  after  it 
has  once  become  well  established.  The  outlook  for 
these  patients  as  regards  a  perfect  or  permanent  cure 
is  generally  bad. 

It  has  been  customary  of  late  years  for  most  writers 
on  insanity  to  consider  this  form  as  a  separate  species, 
a  well-defined  clinical  entity.  There  are  some  grounds 
for  this,  and  we  have  hesitated  somewhat  in  combining 


ADOLESCENT  INSANITY.  303 

it  with  ordinary  adolescent  insanity  under  the  one 
head.  If  we  consider  all  cases  accompanied  with 
muscular  rigidity  as  belonging  to  this  type,  we  will  have 
to  admit  that  it  occurs  at  more  advanced  ages  than 
would  naturally  be  expected  in  a  species  especially 
attending  the  changes  of  youth  and  early  maturity. 
The  catatonic  symptoms,  however,  may  occur  in  other 
conditions  differing  rather  widely  from  the  general  syn- 
drome here  described;  it  may  occur  in  hysteric  and 
epileptic  states  and  other  insanities,  even  in  the  organic 
dementia  of  old  age.  Moreover,  the  present  type  in 
nearly  all  the  cases  we  have  seen  it  had  its  beginnings, 
at  least,  within  the  period  we  have  assigned  as  that  of 
adolescent  insanity.  We  have  also  observed  cases  that 
suggested  transition  forms  between  this  and  the  typical 
adolescent  forms,  while  we  have  ourselves  never  seen  a 
well-marked  case  with  the  characteristic  symptoms 
well  marked  of  muscular  tension  and  verbigeration  in  a 
person  over  thirty  years  of  age.  It  appears  to  us  that 
it  can  be  better  classed  as  a  special  form  of  adolescent 
insanity  than  as  a  species,  hence  its  inclusion  here.  It 
may  have  special  exciting  causes ;  it  is  said  to  frequently 
originate  after  childbirth  in  young  women,  but  the  real 
cause  in  the  vast  majority  is,  we  think,  the  failure  of  a 
degenerate  brain  to  meet  the  strains  attendant  on 
development,  especially  sexual  development  in  youth 
or  early  maturity. 

The  general  course  of  all  adolescent  insanity  as  here 
understood  is  toward  more  or  less  complete  mental 
breakdown.  In  some  cases  this  is  rapid  and  pronounced, 
in  others  it  may  appear  slowly  or  be  incomplete,  but  in 
nearly  all,  if  not  all,  the  deterioration  occurs  and  is 
sufficiently  manifest.  In  the  catatonic  cases  there  may 
be,  as  stated  already,  an  apparent  temporary  cure,  but 
its  prognosis  is  also  bad. 

Clouston,  whose  conception  of  adolescent  insanity  is 
different  from  ours,  including  some  of  what  we  call  the 


304  INSANITIES    OF    CRITICAL    PERIODS. 

borderland  conditions,  as  well  as  the  non-characteristic 
types  occurring  at  this  period,  says  that  about  60%  of 
cases  recover.  This  is  certainly  not  true  of  the  disorder 
as  here  understood  and  considered. 

The  diagnosis  of  adolescent  insanity  is,  as  a  rule,  not 
difficult  in  typical  cases.  Where  the  insanity  begins 
in  early  life  with  the  well-marked  character  of  a  silly 
dementia  pervading  all  the  symptoms,  and  when  the 
later  course  of  the  disorder  is  complete  dementia, 
the  case,  if  watched,  is  generally  readily  classified. 
So,  too,  in  the  typical  catatonic  case,  with  its  changing 
phases  of  depression,  excitement,  stupor,  with  rigidity 
and  the  characteristic  remissions  and  verbigeration, 
there  is  little  difficulty.  When  first  seen,  however, 
before  the  case  can  be  watched  for  any  time,  it  is 
possible  to  confuse  these  patients  with  maniacs,  simple 
melancholiacs,  confusional  delirious  cases,  and  para- 
noiacs,  according  to  the  special  symptoms  manifested 
at  the  time.  In  most  instances,  with  care,  the  differ- 
ences can  be  detected;  the  maniacal  and  melancholic 
symptoms  are  less  intense  than  in  the  typical  forms; 
the  delusions  less  systematized  and  fixed  than  in  para- 
noia; and  in  all  cases  the  rapid  tendency  to  dementia 
is  a  valuable  guide  to  the  diagnosis.  There  will  be 
probably  most  difficulty  in  distinguishing  adolescent 
insanity  from  some  forms  of  confusional  insanity, 
but  the  course,  causes,  and  history  of  the  case  will 
generally  aid  the  observer  to  come  to  a  correct  conclu- 
sion. There  is  some  resemblance  often  to  certain  types 
of  imbecility,  and  that  form  we  have  described  as 
original  paranoia,  which  is  a  sort  of  imbecility,  has  some 
resemblance  in  the  time  of  its  appearance,  but  its  evolu- 
tion is  altogether  different,  as  also  the  mental  syndrome, 
and  the  presence  of  marked  degenerative  stigmata  is 
also  a  prominent  distinguishing  characteristic.  The 
manner  of  onset  of  the  insanity  and  the  peculiar 
theatrical  manner  often  exhibited  by  these  patients  are, 


ADOLESCENT  INSANITY.  305 

with  the  rapidly  appearing  dementia,  and  with  the  age 
at  which  it  appears,  sufficiently  striking  to  make  the 
diagnosis  usually  easy. 

The  treatment  of  adolescent  insanity  is  generally 
symptomatic;  there  is  no  special  or  peculiar  line  of 
conduct  indicated.  The  same  attention  must  be  given 
to  nutrition,  elimination,  and  the  securing  of  rest  and 
sleep  as  is  required  in  other  forms  of  insanity  with 
corresponding  symptoms.  In  most  cases  hospital  treat- 
ment is  advisable ;  at  any  rate,  some  change  from  home 
surroundings  and  associations.  These  patients  are  not 
safe  to  be  at  large,  and  should,  therefore,  be  under 
supervision,  which  can  best  be  given  in  a  hospital  for 
the  insane.  Generally,  as  has  been  already  said,  neither 
the  excitement  nor  the  depression  is  so  intense  as  in 
acute  mania  or  melancholia,  but  in  some  cases  sedative 
drugs  or  measures  may  be  required  at  times. 

The  prophylaxis  of  this  type  of  insanity  is  naturally 
suggested  as  possible,  but  too  much  must  not  be  ex- 
pected in  this  direction.  If  it  were  always  possible  to 
foresee  the  outbreak,  or  even  to  diagnose  it  early  in 
many  cases,  more  could  be  done.  When  a  liability  to 
this  disorder  is  suspected,  careful  training,  avoidance 
of  mental  strain,  overstudy,  and  abnormal  sexual  ex- 
citement, and  a  healthy  normal  life,  largely  out-of- 
doors,  with  due  care  as  to  the  physical  health  in  all 
particulars,  probably  give  the  best  chances  of  avoiding 
it.  We  can,  however,  make  only  general  recommenda- 
tions, and  have  to  remember  that,  as  a  rule,  we  have 
here  the  evidence  of  original  imperfections  of  the  higher 
nervous  centers  that  handicap  the  individual  even 
more  than  in  many  other  forms  of  mental  disease.  It 
is  essentially,  in  all  its  forms,  a  degenerative  type  of 
insanity. 


306  INSANITIES    OF    CRITICAL    PERIODS. 


CLIMACTERIC  INSANITY. 
The  insanity  occurring  at  the  climacteric  period  has 
not,  in  our  experience,  any  specific  characters;  it  is 
simply  mental  breakdown  from  inherent  weakness 
occurring  during  or  brought  on  by  conditions  of  physi- 
cal ill  health  at  this  time.  Melancholia  is  perhaps  the 
most  frequent  type,  but  other  forms  are  not  rare.  In 
some  cases  the  change  from  active  sexual  life  to  the 
comparative  quiet  of  normal  post-reproductive  exist- 
ence has  a  beneficial  effect,  and  some  very  striking 
recoveries  from  insanity  of  long  duration  have  been 
observed  at,  or  rather  after,  the  change  of  life.  The 
mental  stress  of  this  period  may  also,  though  rarely, 
be  observed  in  men  as  well  as  in  women,  and  a  recent 
author  (Bombarda)  has  called  especial  attention  to 
this  fact.  In  neither  sex,  however,  is  the  type  of  in- 
sanity uniform  or  characteristic. 

SENILE  INSANITY. 
A  certain  degree  of  decay  of  the  mental  powers  is  a 
natural  consequence  of  advanced  age.  It  may,  there- 
fore, within  certain  limits,  be  considered  a  normal 
change,  these  limits  being  marked  by  slight  failures  of 
memory  or  capacity  for  mental  work.  Exceptional 
individuals  preserve  their  mental  with  their  physical 
powers  apparently  intact  or  but  very  slightly  deterior- 
ated to  an  age  long  after  the  average  man  has  shown 
signs  of  weakness  or  breakdown,  and  in  a  somewhat 
larger  proportion  of  cases  the  intellect  seems  to  preserve 
its  powers  in  a  more  or  less  enfeebled  physical  organiza- 
tion. The  average  man,  however,  begins  to  feel  that 
he  has  passed  his  best  days  at  sixty  to  sixty-five,  and  in 
a  very  great  many  instances  even  earlier.  The  memory 
is  not  what  it  was ;  the  capacity  for  original  work,  the 
ambitions,  are  lost  to  some  extent,  and  as  age  advances 
this  is  still  more  apparent  to  the  individual  and  those 


Senile  insanity. 


SENILE    INSANITY.  307 

about  him.     This  is  only  the  normal  course  of  old  age; 
it  falls  short  of  mental  disease. 

In  many  cases  the  changes  are  still  more  marked, 
the  loss  of  mental  power  is  very  clearly  evident,  and 
we  say  the  man  is  in  his  dotage  or  his  second  childhood. 
This  is  the  milder  type  of  senile  dementia,  that  is 
hardly  reckoned  as  mental  disease.  When  it  is  still 
more  pronounced,  when  the  sufferer  is  incapable  of 
self -guidance  or  care,  and  especially  when  he  loses  the 
ordinary  natural  inhibitions  on  conduct  that  are  essen- 
tial in  society,  dementia  is  recognized  by  all.  A  not 
uncommon  form  is  that  in  which  the  patient  can  con- 
trol himself  and  appear  even  sensible  when  talking  of 
the  remote  past,  but  loses  himself  completely  as  re- 
gards more  recent  happenings  or  the  events  of  the  day, 
in  which  he  may  take  an  apparent  interest,  but  forget 
as  soon  as  they  are  past  in  time.  The  mental  machine 
is  still  good  for  repeating  its  old  tasks,  but  can  do 
nothing  with  the  present  or  the  new.  In  many  of 
these  cases  there  is  clear  evidence  of  organic  disease 
of  the  cerebrum;  there  may  have  been  apoplectic 
attacks,  temporary  spells  of  aphasia,  vertigos,  or  con- 
vulsions. There  is  frequently  in  these  cases  irrita- 
bility with  depression  that  may  make  the  patient 
dangerous  to  himself  or  others.  A  typical  melancholia 
may  be  an  early  symptom ;  indeed,  Kraepelin  considers 
this  form  of  insanity  characteristic  of  beginning 
senility.  It  is  certainly  a  common  type  of  the  insanity 
of  advanced  age,  but  in  our  experience  may  also  often 
occur  in  its  typical  form  in  the  young,  and  cannot, 
therefore,  be  counted  as  exclusively  a  senile  disorder. 
Another  common,  or  not  very  infrequent,  type  is  a  sort 
of  moral  deterioration  leading  to  offenses  against  the 
law  and  against  good  morals,  or  making  the  subject  a 
nuisance  to  his  family  and  friends  by  his  outbreaks  and 
transgressions  and  his  unpleasant  irritable  disposition. 
In  some  cases  the  mental  derangement  of  senility  will 


308  INSANITIES    OF    CRITICAL    PERIODS. 

take  the  form  of  delusions  of  persecution,  the  enemies 
and  persecutors  being  members,  it  may  be,  of  the 
patient's  own  family.  Cases  have  occurred  where  such 
delusions  have  led  to  disinheritance  of  children,  and 
the  apparent  mental  soundness  on  other  points  has 
defeated  all  attempts  to  break  the  will  and  defeat  the 
injustice.  Patients  of  this  kind  often  become  the 
victims  of  designing  women,  and  make  silly  marriages, 
to  their  own  and  others'  disadvantage.  There  is 
scarcely  any  foolish  act  that  may  not  be  committed  by 
those  suffering  from  some  of  the  forms  of  incipient 
senile  dementia ;  a  noted  statesman  becomes  the  victim 
of  a  spiritualistic  swindler;  a  distinguished  scientific 
physician  may  indorse  arrant  quackery.  The  chief 
characteristic  features  are  a  weakened  judgment,  a  lack 
of  control  of  impulses,  a  childish  caprice,  and  often  a 
marked  ethical  insensibility. 

We  may,  when  considering  the  more  advanced  forms 
of  senile  mental  derangement,  make  a  distinction  be- 
tween those  associated  with  well-marked  organic  brain 
changes  and  those  where  these  are  not  manifest.  In 
the  former  class  we  can  put  those  cases  where  hemi- 
plegic  or  apoplectic  attacks,  paretic  conditions,  speech 
defects,  pupillary  symptoms,  such  as  irregularity,  dis- 
ordered reflexes,  etc.,  exist.  These  are  common,  and 
occasionally  give  the  case  a  strong  suggestion  of  paresis, 
which  is  aided  by  the  extravagances  and  delusions 
with  the  progressive  mental  enfeeblement.  It  is  prob- 
able that  the  majority  of  the  cases  of  paresis  reported 
at  over  fifty  years  of  age,  if  not  indeed  all  of  them,  can 
be  better  referred  to  this  form  of  organic  senile  demen- 
tia. Indeed,  we  believe  that  all  such  cases  over  sixty 
are  of  this  class.  In  the  more  advanced  stages  the 
dementia  very  commonly  becomes  complete,  and  the 
patient  lives  a  merely  vegetative  existence,  requiring 
close  personal  attention  for  even  the  ordinary  organic 
functions  to  be  properly  carried  on. 


SENILE    INSANITY.  309 

When  the  insanity  is  not  connected  with  gross  brain 
disease  other  than  those  conditions  usual  in  old  age, 
it  may  take  on  any  form — melancholia,  mania,  delu- 
sional paranoia,  acute  delirium,  circular  insanity,  or 
gradually  advancing  dementia.  The  melancholic  cases 
are  most  common,  and  there  is  less  of  a  special  character 
to  the  derangement  than  is  common  in  the  other  forms. 
In  many  cases  the  melancholia  is  typical,  with  pre- 
cardial  distress,  self -accusation,  tendency  to  suicide, 
and  all  the  other  characteristic  symptoms.  These 
cases  are,  however,  in  our  experience  mostly  in  early 
senility,  before  the  brain  changes  have  become  so 
advanced;  that  is,  in  the  sixth  and  the  early  part  of 
the  seventh  decades.  In  more  advanced  years  the 
depression  is  not  so  serious,  in  its  manifestations  at 
least,  and  the  suicidal  tendencies  and  agitations  are 
less  prominent.  Nevertheless,  the  suicidal  impulse 
may  be  strong  in  these  cases  when  the  depression  ap- 
pears to  be  only  moderate,  and  all  due  caution  is  need- 
ful, as  the  unexpected  may  happen  at  any  time.  We 
have  known  a  patient  of  this  sort,  whose  mental  con- 
dition was  hardly  one  to  suggest  such  a  tendency,  to 
strangle  himself  with  a  torn  strip  of  cloth  in  his  bed,  a 
performance  that  must  have  required  unusual  deter- 
mination and  a  very  persistent  impulse. 

Maniacal  conditions  are  much  less  frequent,  and  vary 
in  type  from  mild  hypomania  to  a  rather  high  grade  of 
excitement,  though  the  extreme  forms  are  seldom  seen. 
In  these  conditions  there  are  not  infrequently  delu- 
sions of  a  puerile  or  childish  nature.  We  have  seen  a 
patient  of  nearly  seventy  years  of  age,  physically  well 
preserved,  and  active,  in  a  state  of  mild  maniacal  ex- 
citement full  of  notions  about  fighting  Indians  and 
trapping  and  mining  in  the  West,  like  a  boy  under  the 
influence  of  too  much  dime-novel  reading.  He  staked 
out  mining  claims  over  all  parts  of  the  asylum  farm 
where  he  could  go  on  his  walks,  and  was  a  constant 


3IO  INSANITIES    OF    CRITICAL    PERIODS. 

source  of  anxiety  lest  he  should  secure  something 
dangerous  in  his  outings,  not  so  much  with  the  idea  of 
using  it  against  his  attendants  as  against  the  savages 
he  was  preparing  to  meet  when  he  made  his  escape. 
He  had  to  be  constantly  searched  whenever  he  returned 
from  an  outing,  and  on  several  occasions  made  his 
escape  and  secured  corn  knives  or  something  similar 
from  barns  and  outhouses.  He  was  by  no  means  really 
dangerous,  but  on  one  or  two  of  these  occasions  he  suc- 
ceeded, to  his  own  satisfaction,  in  terrifying  persons 
he  met,  and  once  had  a  whole  village  in  an  uproar.  He 
was  usually  easily  recaptured,  but  his  accounts  of 
asylum  treatment,  when  on  his  escapades,  were  enough 
to  set  up  a  legislative  investigation,  and  it  was  not 
considered  desirable  to  have  him  at  large.  As  he  was 
very  evasive  and  cunning  in  his  way,  he  several  times 
made  his  escape,  but  was  always  heard  from  immedi- 
ately, as  his  performances  quickly  revealed  where  he 
belonged.  In  this  case,  as  in  some  other  similar  ones, 
the  patient  made  an  approximate  recovery,  and  was 
not  heard  from  again  as  insane,  at  least,  not  for  a  num- 
ber of  years. 

In  other  cases  we  may  have  a  senile  confusional 
delirium,  a  paranoia,  or  circular  insanity;  they  are 
simply  ordinary  instances  of  these  types  of  insanity 
occurring  in  and  colored  by  senility.  The  natural 
senile  changes  in  the  brain  may  favor  any  kind  of 
mental  failure  in  predisposed  individuals  or  under 
conditions  of  special  stress,  as  at  other  periods  of  life ; 
and  when  they  occur,  put  on  them  the  special  stamp 
of  senile  insanity,  which  is  liable  to  be,  as  in  the  case 
above  mentioned,  a  sort  of  childish  weakness;  the 
memories  and  tendencies  of  the  earlier  life  still  remain- 
ing and  predominating  over  the  more  recent  cerebral 
acquisitions.  Thus  we  see  in  some  of  these  cases 
curious  tendencies  to  collecting  rubbish,  trifling  objects, 
etc.,  returning,  as  it  were,  to  the  tastes  and  fancies  of 


SENILE    INSANITY.  311 

childhood.  The  prevailing  note  in  the  senile  insanities 
is  the  non-realization  of  the  present  and  the  renewal 
or  survival  only  of  the  past. 

It  is  difficult  to  draw  any  arbitrary  or  exact  line  be- 
tween the  functional  insanities,  so  to  speak,  of  the  aged 
and  those  connected  with  gross  brain  disease.  It  is 
only  the  very  evidently  casual  affections,  influenced 
by  heredity  acting  with  the  mild  general  cerebral  im- 
pairment of  senility,  that  can  be  properly  said  to  be 
unconnected  with  the  graver  changes.  In  all  cases,  of 
course,  there  must  be  senile  impairment,  but  in  these 
it  would  not  have  revealed  itself  in  insanity  but  for 
these  other  causes.  In  the  greater  proportion  the 
mental  disorder  is  itself  the  direct  cause,  and  the  effect 
may  show  itself  in  the  various  ways  above  described. 
In  addition,  one  or  two  other  forms  may  be  here  men- 
tioned, such  as  the  hallucinatory  delirium  that  some- 
times appears  in  this  condition,  which  resembles  acute 
delirium,  and  may  be  accompanied  with  febrile  tem- 
perature and  other  signs  of  maniacal  inflammation. 
It  is  not  always  fatal,  and  is  one  of  the  features  that 
counterfeit  paresis  in  some  of  its  manifestations. 

The  pathology  of  senile  insanity,  in  a  general  way, 
may  be  said  to  be  that  of  arterial  degeneration  involv- 
ing the  nutrition  of  the  brain.  ' '  A  man  is  as  old  as  his 
arteries"  is  an  approved  medical  saw,  and,  we  may 
add,  he  is  very  often  insane  in  proportion  as  his  cerebral 
arteries  are  diseased.  The  pathologic  findings  corre- 
spond with  this  view  of  the  nature  of  the  condition ;  we 
have  wasting  of  the  brain,  atrophy  of  the  cells,  thick- 
ening and  loss  of  elasticity  of  the  arterial  coats,  with 
frequent  miliary  aneurysms,  and  minute  hemorrhagic 
effusion.  In  the  advanced  cases  of  these  conditions 
we  may  find  thickening  of  the  membranes,  evidences 
of  old  inflammations,  etc.,  and  in  the  gross  organic 
cases  we  have  hemorrhagic  foci  and  patches  of  soften- 
ing, and    sometimes  organized  clots   and  false  mem- 


312  INSANITIES    OF    CRITICAL    PERIODS. 

branes.  There  is  hardly  any  form  of  gross  cerebral 
disease  that  may  not  reveal  its  old  lesions  in  the 
autopsies  of  senile  insanity.  It  is  often  the  case  that 
the  outbreak  or  appearance  of  mental  disease  in  the 
aged  is  seen  as  the  apparent  immediate  result  of  some 
injury  or  disease  that  may  itself  leave  its  special  traces 
or  modify  those  otherwise  produced. 

The  diagnosis  of  senile  insanity  is  usually  easy;  the 
fact  is  that  almost  any  appearance  of  mental  disorder 
at  an  advanced  age  is  apt  to  be  so  far  colored  by  the 
senility  as  to  be  deserving  of  the  name.  It  is  only  in 
those  cases  that  occur  comparatively  early,  in  the  sixth 
and  seventh  decades  of  life,  that  we  are  likely  to  ques- 
tion their  proper  reference.  It  must  not  be  forgotten, 
also,  that  there  may  occur  insanities  in  special  cases  of 
unusually  vigorous  individuals  at  a  very  advanced  age 
that  have  nothing  about  them  absolutely  character- 
istic of  the  changes  of  old  age.  Thus,  we  have  seen  a 
circular  insanity  in  an  old  man  which  was  in  nowise 
very  dissimilar  to  that  occurring  in  much  younger 
persons ;  it  was  of  the  severer  type,  with  decided  mania 
in  the  exalted  stage  and  nearly  complete  stupor  in  the 
depressed  phase.  These  cases  are,  however,  compara- 
tively rare,  and  even  they  are  not  usually  so  free  from 
the  tinge  of  senility  as  was  the  one  above  mentioned. 
Melancholia  in  the  elderly  is  not  specially  dissimilar 
from  that  in  the  young,  though  it  has  not  so  often  the 
symptoms  of  extreme  agitation.  It  is  in  those  cases 
that  resemble  paresis  that  a  mistake  is,  we  think,  most 
often  made,  and  reference  has  already  been  made  to 
the  probable  false  diagnosis  in  many  of  these  cases. 

It  is  not  possible  to  always  draw  the  line  between 
the  ordinary  symptoms  of  senile  mental  weakness  that 
cannot  properly  be  ranked  as  insanity  and  those  of 
actual  mental  disease.  This  should  be  kept  in  mind; 
a  man  may  be  weak  in  memory,  especially  of  recent 
events,  and  may,  in  fact,  be  an  example  of  the  sudden 


SENILE    INSANITY.  313 

or  incipient  form  of  dementia  of  old  age  in  some 
respects,  but  still  be,  in  the  main,  of  "  sound  and  devis- 
ing mind,"  as  the  legal  language  expresses  it.  This 
is  a  matter  of  importance  in  will  cases,  and  the  nature 
of  the  will  itself,  in  such  instances,  is  often  strong 
evidence.  If  it  shows  unreasonable  likes  and  dislikes, 
or  signs  of  delusions,  it  may  be  conclusive  if  sole  evi- 
dence of  disordered  intellection.  The  moral  defects 
noted  in  other  cases,  the  immoralities,  obscenities, 
financial  extravagances,  etc.,  may  be  the  only  symp- 
toms that  make  us  certain  that  the  case  passes  over 
the  border  of  sanity  into  that  of  unquestionable  mental 
disease.  The  patient  in  this,  as  in  other  cases,  must  be 
compared  with  his  normal  self,  and  while  allowance  is 
made  for  the  general  and  usual  changes  of  senility, — 
the  changes  in  memory,  in  the  emotional  capacity  and 
control, — any  marked  differences  in  character  will  go 
far  to  place  it  on  the  wrong  side.  It  must  be  remem- 
bered, also,  that  senile  delusional  insanity,  like  that 
of  earlier  life,  may  develop  without  very  observable 
general  or  special  failure  in  other  directions. 

The  treatment  of  senile  insanity  may  be  given  briefly. 
It  is  mainly  symptomatic.  In  cases  of  general  mental 
failure  the  most  that  can  be  done  is  to  protect  the 
patient  from  injury,  watch  his  wanderings,  and  at- 
tend to  his  bodily  necessities.  In  the  acute  psychoses 
of  old  age  the  treatment  is  practically  the  same  as  in 
the  similar  forms  in  younger  patients,  due  allowance 
being  made  for  age  and  physical  condition.  The 
suicidal  tendency  in  melancholia  is  to  be  'especially 
guarded  against,  the  more  as  it  may  be  less  evident 
than  in  younger  patients.  Organic  dementia,  and 
cases  showing  very  decided  atheromatous  conditions 
of  the  vessels,  have,  of  course,  their  own  special  indica- 
tions and  cautions.  The  senile  dement  especially 
needs  a  kindly  but  firm  control ;  he  is  commonly  easily 
managed,  but  may  be  very  trying  to  his  caretaker. 


CHAPTER  XVII. 
DEGENERATIVE  INSANITIES, 

We  understand  by  the  degenerative  insanities  that 
class  of  mental  disorders  associated  with  and  caused 
by  more  or  less  permanent  and  incurable  structural  or 
functional  defects,  usually  congenital  and  hereditary. 
We  say  more  or  less  permanent  and  incurable  because, 
while  in  the  great  majority  of  cases  they  are  permanent 
and  incurable,  it  is  not  intended  to  deny  the  possibility 
of  changes  taking  place,  under  favorable  conditions, 
such  as  to  correct  or  compensate  for  the  defects.  The 
predisposition  to  insanity  through  general  weakness  or 
lack  of  resistance  of  the  organism  is,  of  course,  not  in- 
cluded here ;  the  difference  between  the  two  conditions 
is  that  in  the  one  we  may  have  a  weak  or  weakened 
brain,  while  in  the  other  the  condition  is  that  of  original 
lack  of  balance  in  some  respect  or  other,  revealing  itself 
either  in  more  or  less  serious  and  permanent  mental 
aberration,  or  in  erratic  breakdowns,  occurring  from 
time  to  time.  The  one  is  like  a  machine  of  general  in- 
ferior workmanship  or  worn  out ;  the  other,  like  one  that 
is  badly  constructed  in  some  special  part,  affecting  its 
working  either  generally  or  at  times.  It  does  not  neces- 
sarily follow  that  these  insanities  are  always  incurable, 
though  that  is  their  tendency ;  there  is  a  possibility  that 
the  defects  may  be  in  some  way  compensated  for  and 
the  mental  workings  become  normal.  In  many  instances, 
indeed,  the  degenerative  defects  may  be  only  slight  and 
the  patient  never  entirely  overstep  the  borderland  of 
sanity ;  he  may  be  only  regarded  as  eccentric  or  a  crank, 
or  subject  to  moods  and  spells.  More  will  be  said  in 
regard  to  this  point  when  discussing  some  of  the  special 

314 


DEGENERATIVE    TYPES.  315 

types  of  this  general  class  of  mental  disorders.  In  a 
large  proportion  of  cases,  however,  the  condition  is 
manifested  in  recurrent  or  cyclic  attacks  of  mental 
disorder  occurring  sometimes  after  shocks,  mental 
strain,  etc.,  but  also  very  frequently  without  obvious 
cause.  In  other  cases  the  insanity  takes  on  the  form 
of  systematized  delusions,  and  in  still  others  the  condi- 
tion graduates  into  imbecility  through  such  types  as 
the  origindre  verrucktheit  of  certain  German  writers, 
moral  insanity,  reasoning  mania,  etc.  A  character- 
istic of  this  group  of  insanities  is  the  very  general  bad 
neuropathic  or  insane  heredity;  they  are  the  most 
hereditary  of  all  insanities. 

There  has,  as  has  been  already  stated,  been  a  general 
confusion  of  some  of  these  types  with  confusional  in- 
sanity, or  perhaps  we  should  express  it  that  confusional 
insanity  has  been  confounded  in  some  of  its  types  with 
the  commoner  simpler  type  of  degenerative  recurrent 
insanity.  It  is  the  merit  of  Kraepelin  that  he  first 
clearly  pointed  out  the  distinction,  and  recognized  the 
fact  that  acute  mania  in  its  typical  restricted  sense  is 
properly  a  degenerative  type.  We  do  not  here  follow 
him  in  every  particular,  but  must  recognize  this  fact, 
which  is  of  importance  in  estimating  the  future  course 
and  probabilities.  A  prominent  feature  of  what  we 
may  call  the  lighter  forms  of  the  degenerative  insanities 
is  their  tendency  to  recurrence,  and  this  may  be  regular 
and  periodic  or  irregular,  the  latter  being  the  character 
of  what,  for  convenience'  sake,  we  here  take  and  con- 
sider as  the  least  markedly  degenerative,  recurrent 
maniacal  insanity,  or  simple  mania.  There  is  an  occa- 
sionally recurrent  form  of  melancholia  also,  but  that, 
when  not  associated  with  the  maniacal  type,  is  gener- 
ally, in  our  opinion,  a  form  due  to  general  neurasthenic 
weakness  in  this  direction,  and  not  a  true  degenerative 
type.  An  individual  may  be  neurasthenic  and  natur- 
ally below  tone,  as,  in  fact,  many  are,  and  true  melan- 


o 


1 6  DEGENERATIVE    INSANITIES. 


cholia  of  this  character  forms  an  occasional  episode  in 
his  existence,  under  conditions  of  stress  and  overwork. 
If  there  is  a  true  degenerative  periodic  or  recurrent 
melancholia,  it  is  most  probably  a  modified  or  disguised 
form  of  circular  insanity  with  special  predominance  of 
the  depressive  phase.  Cases  of  this  kind  occur  in  which 
only  close  observation  can  distinguish  the  phase  of 
excitement,  which  nevertheless  exists,  though  not  to 
the  extent  to  render  mental  disorder  very  noticeable 
except  to  a  skilled  observer. 

The  neurasthenic  phobias  and  obsessions  have  been 
recognized  by  some  writers  as  pertaining  to  the  degen- 
erative insanities,  but  this  is  by  no  means  the  universal 
rule;  they  may  occur  in  individuals  who  are,  to  no 
marked  extent  at  least,  degenerates.  They  are,  it  is 
true,  most  frequently  associated  with  a  defective  or 
neuropathic  constitution,  in  which  the  normal  inhibi- 
tions to  their  manifestations  or  continuance  are  lack- 
ing, but  this  is  not  by  any  means  invariably  the  case. 
They  are  best  to  be  considered  as  a  class  by  themselves, 
so  far  as  they  fall,  by  their  intensity  and  degree  of 
development,  into  the  actual  insanities. 

Hysteria  is  also  to  be  regarded  as  a  degenerative 
psychosis  in  many  of  its  aspects,  but  it  is  only  in  its 
extreme  manifestations  that  it  falls  within  the  defini- 
tion of  insanity.  Hysteric  insanity  has  been  noticed  in 
connection  with  certain  other  special  neuropathic  types, 
already  mentioned  in  a  special  group  of  this  general 
division  of  mental  disorders. 


RECURRENT  DEGENERATIVE  MANIA. 
While  Kraepelin,  whom  we  follow  in  placing  mania 
in  this  general  class,  has  given  it  the  name  of  periodic 
insanity,  we  prefer  to  use  the  term  recurrent,  as 
better  indicating  its  manner  of  reappearance.  "Peri- 
odic"   implies    a    regular    return    at    stated    periods; 


RECURRENT    DEGENERATIVE    MANIA.  317 

"recurrent"  only  indicates  its  tendency  to  recur,  and 
the  general  permanent  tendency  to  attacks. 

Etiology. — The  most  striking  general  etiologic  fact 
is  the  hereditary  character  of  the  disorder.  When  the 
family  history  is  fully  ascertained,  it  is  almost  univer- 
sally found  that  there  has  been  in  the  ancestry  some 
degenerative  taint,  often  a  direct  heredity  of  insanity 
or  eccentricity  verging  on  mental  disorder.  In  a  few 
cases  this  cannot  be  found,  but  there  is  frequently, 
then,  some  manifestation  in  the  collateral  lines  that 
shows  the  defective  nervous  organization.  In  some 
instances  it  is  possible  that  a  marriage  may  occur 
between  persons  of  normal  constitution,  but  so  unsuited 
to  each  other  as  to  cause  serious  brain  or  nerve  defect 
in  their  offspring,  who  are,  as  a  result,  subjects  of  this 
or  some  other  degenerative  type  of  mental  disease, 
without  any  history  of  direct  ancestral  heredity.  Such 
cases  are  unusual,  however,  and,  as  a  rule,  the  record 
indicates  the  source  of  the  taint.  The  immediate  ex- 
citing cause  of  an  attack  of  mania  may  be  any  one  of 
the  ordinary  direct  causes  of  insanity — moral  or  emo- 
tional stress,  or  shock,  ill  health,  the  puerperal  condi- 
tion, etc.  It  is  easy  to  see  how  any  one  of  these  may 
give  rise  to  the  mental  disorder  in  a  thus  constitution- 
ally predisposed  subject.  It  is  a  striking  fact,  how- 
ever, that  in  many  cases  of  mania  no  direct  exciting 
cause  whatever  can  be  found  for  even  the  first  attack. 
Subsequent  attacks  may  or  may  not  have  provocation ; 
not  infrequently  they  occur  without  warning  or 
apparent  reason.  The  subjects  frequently  show  an 
instability  and  excitability  of  character,  but  this  is  not 
always  apparent,  nor  are  there  always  visible  marked 
degenerative  stigmata.  The  attacks  have  been  said 
by  some  to  occur  in  the  spring  months  more  than  at 
other  times  in  the  year,  but  such  generalizations  from 
partial  statistics  are  not  very  valuable.  The  fact  that 
mania  has  been  generally  confused  up  to  the  present 


3l8  DEGENERATIVE    INSANITIES. 

with  the  excited  types  of  confusional  insanity  makes 
them  practically  valueless. 

Symptoms. — The  earliest  symptoms  of  simple  acute 
mania  vary  much  in  different  cases.  Often,  perhaps 
generally,  there  is  a  stage  of  restlessness  or  mild  depres- 
sion preceding  the  attack  for  from  one  to  several  days,  or 
it  may  be  weeks,  but  this  is  often  wanting  or  impossible 
to  be  detected.  Its  occurrence  is  an  indication  of  the 
general  cyclic  tendency  of  these  degenerative  insanities. 
When  this  is  absent,  as  appears  to  be  sometimes  the 
case,  the  onset  is  often  immediate  and  abrupt;  the 
patient  passes  more  or  less  rapidly  into  the  state  of 
full-fledged  motor  and  mental  excitement.  In  most 
cases,  however,  there  has  probably  been  some  derange- 
ment of  the  bodily  functions,  not  always  very  obvious, 
such  as  insomnia,  more  or  less  pronounced,  or  at  least 
some  disturbance  of  sleep,  and  constipation  is  evidently 
a  very  common  antecedent.  Sometimes  there  is  a 
period  in  which  oscillations  of  quiet  and  mild  excite- 
ment succeed  each  other,  gradually  developing  into 
the  complete  attack.  In  the  most  typical  form  the 
onset  of  the  symptoms  is  exceedingly  rapid ;  it  may  be, 
as  it  were,  instantaneous;  in  one  case  known  to  the 
writers  the  first  observable  symptoms  were  the  patient's 
throwing  her  effects  and  money  out  of  a  car  window  as 
she  was  traveling,  and  in  many  instances  the  outbreak 
is  apparently  as  sudden  as  this.  We  say  apparently, 
for  the  initial  symptoms  of  unlooked-for  outbreaks  may 
easily  pass  unperceived,  but  there  are  probably  many 
cases,  as  is  more  often  observed  in  recurrent  attacks, 
where  there  are  practically  no  premonitory  signs 
whatever. 

Whether  gradual  or  sudden  in  its  beginning,  the 
mental  condition  soon  becomes  characteristic;  the 
ideation  is  greatly  intensified,  the  ideas  tumbling  over 
each  other,  so  to  speak,  in  their  rapid  evolution;  the 
attention  power  lengthened  so  that  the  patient  is  alive 


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RECURRENT    DEGENERATIVE    MANIA.  319 

to  every  fleeting  impression,  but  the  possibility  of  its 
steady  concentration  absolutely  lost,  the  result  being 
ideorrhea  without  system  and  general  mental  exalta- 
tion and  deranged  excitation.  With  this  mental  there 
is  also  emotional  excitement,  the  general  type  of  which 
is  lively  and  cheerful  rather  than  otherwise,  though 
there  are  sudden  and  rapid  emotional  changes;  the 
patient  may  be  maudlin  one  moment  and  hilarious  the 
next.  There  is  usually  also  a  great  exaltation  of  self- 
consciousness  and  a  feeling  of  power,  and  all  these 
reveal  themselves  externally  by  incessant  action,  a 
constant  flow  of  words,  and  very  often  tendencies  to 
destroy  articles  in  their  surroundings,  their  clothing, 
etc.  This  may  be  due  in  part  to  a  feeling  of  restraint 
by  these  objects,  but  it  is  usually  accounted  for  as  a 
symptom  of  the  general  intense  motor  excitement  and 
unregulated  impulses.  The  patients  laugh,  dance,  sing, 
or  cry,  often  keeping  up  an  intense  disorderly  bodily 
and  mental  activity  for  long  periods  without  rest  or 
showing  any  signs  of  exhaustion.  The  moral  inhibi- 
tions are  commonly  lost,  and  the  sexual  impulses  are 
likely  to  be  exaggerated,  so  that  refined  and  religious 
women  may  be  profane  and  indecent  in  gesture  and 
language.  The  perception  unguided  by  judgment  and 
the  random  ideation  give  rise  to  various  illusions,  which 
are  a  characteristic  feature  of  this  form  of  mental  dis- 
order. The  patient  is,  as  Regis  says,  acting  a  dream, 
each  impression  starts  a  new  train  of  thought  and 
mental  illusions,  and  every  new  name  or  face  calls  up 
a  train  of  associations  which,  with  the  sensory  exalta- 
tion and  hyperesthesia  that  exist,  creates  the  wildest 
self-deceptions.  Those  about  them  are  recognized  as 
other  persons  than  they  really  are,  and  even  as  animals 
or  reptiles,  etc.  Sometimes  these  illusions  are  terrify- 
ing, often  they  are  not,  but  in  either  way  they  form  the 
starting-point  for  new  mental  and  bodily  activities. 
Actual  hallucinations  are  rare  in  true  mania,  and  when 


320  DEGENERATIVE    INSANITIES. 

they  do  occur  it  is  only  in  very  advanced  conditions  of 
the  disease,  or  from  some  special  cerebral  complication ; 
they  are  in  no  way  characteristic  of  it,  as  they  are  of 
acute  confusional  insanity.  In  mania  we  have  the 
cerebral  mechanism  running  away  with  itself;  in  con- 
fusional insanity  it  is  working  badly  from  general  or 
special  breaking  down  from  overstrain;  and  this  com- 
parison holds  good  throughout  in  their  clinical  mani- 
festations. 

The  bodily  symptoms  of  acute  mania  are  well  marked 
and  prominent;  the  incessant  tendency  to  action,  the 
wild  and  often  hilarious  manner  and  expression,  are 
noticeable  at  first  sight.  Sleep  is  almost  invariably 
affected;  the  patients  seem,  at  least,  not  to  sleep  at  all, 
except  under  the  influence  of  hypnotic  measures  or 
drugs,  for  days  or  weeks  at  a  time;  the  appetite  is 
capricious  and  frequently  lost  or  exaggerated,  the  di- 
gestion disordered,  the  tongue  often  somewhat  furred ; 
constipation  is  likely  to  be  the  rule  in  the  beginning, 
but  later  there  may  be  some  looseness  of  the  bowels. 
While  there  is  often  a  hyperesthesia  of  the  special 
senses  of  sight  and  hearing,  the  general  sensibility  and 
that  to  pain  or  temperature  are  frequently  lowered,  so 
that  the  patient  pays  little  attention  to  heat  or  cold, 
and  is  unmindful  of  bruises  or  injuries.  In  some  ex- 
treme cases  othematoma  may  occur,  but  this  is  very 
rare.  The  sense  of  muscular  fatigue  is  especially  lack- 
ing in  the  excitement,  and  the  patient  keeps  up  his 
activity  under  conditions  that  would  be  impossible 
for  him  in  health,  and  for  almost  incredible  periods 
of  time.  Maniacs  are  not  abnormally  strong;  there  is 
no  actual  increase  of  muscular  power,  for  they  are 
easily  handled  by  careful  but  skilled  attendants,  yet 
they  are  able  in  their  excitement  to  accomplish  feats 
that  seem  impossible,  and  would  be  to  the  ordinary 
individual.  A  woman  weighing  not  over  ninety  to  a 
hundred  pounds,  for  example,  has  been  known,  within 


mania;  hypomania.  321 

the  space  of  a  very  few  minutes,  to  tear  the  stops  of  a 
window  and  to  loosen  the  iron  guards  from  their  screw 
fastenings,  with  her  hands  alone,  a  task  that  could 
hardly  have  been  done  in  less  time  by  a  carpenter  with 
his  tools.  Dr.  Clouston  tells  of  a  woman  who  in  one 
night  tore  up  and  unraveled  her  clothing,  and  in  an- 
other twenty-four  hours  had  constructed  a  complete 
and  tasteful  garment  from  the  materials.  Such  or 
similar  feats  are  not  uncommon  in  the  observation  of 
asylum  physicians,  and  show  the  motor  hyperexcita- 
tion  and  lack  of  sense  of  fatigue  of  these  cases.  The 
pulse  is,  in  the  highest  stages  of  excitement,  naturally 
somewhat  accelerated,  but  in  the  quieter  moments  it 
may  be  nearly  normal ;  at  no  time  in  ordinary  cases 
is  it  febrile.  The  bodily  temperature  is  not  usually 
much  increased,  and  in  excitement  with  destruction 
of  clothing  and  exposure  it  is  sometimes  markedly 
subnormal.  The  bodily  secretions  are  affected;  the 
perspiration  may  be  profuse  and  offensive,  the  urine 
scanty  and  more  toxic  than  normal.  There  is  liable  to 
be  an  excess  of  uric  acid  sediment.  In  women  the 
menses  are  generally  suppressed,  and  in  both  sexes 
there  is  likely  to  be  an  irritation  or  excitation  of  the 
genesic  sense,  leading  to  acts  of  indecency  and  fre- 
quently to  excessive  masturbation. 

In  the  condition  of  extreme  excitement  the  conscious- 
ness is  disordered  to  the  extent  that  the  patients  after- 
ward have  often  only  a  very  indistinct  recollection  of 
their  acts,  but  in  many  cases  it  is  remarkable  how  much 
they  can  recall.  The  memory  does  not  suffer  so  much 
in  this  as  in  confusional  delirium  or  other  forms  of 
insanity  with  excitement. 

Hypomania. — In  the  above  we  have  endeavored  to 
describe  typical  acute  mania,  but  not  all  cases  conform 
to  this  type.  In  some  instances  the  disorder  stops 
short  of  the  extreme  excited  phase,  though  character- 
istic enough  in  other  respects  and  readily  recognizable 


$22  DEGENERATIVE    INSANITIES. 

as  of  the  same  general  species.  In  these  cases  there 
is  the  same  intellectual  hyperexcitation  and  motor 
activity,  but  to  a  lesser  degree;  the  ideation  is  not  so 
tumultuous  and  disorderly,  nor  are  the  activities  so  ill 
regulated.  The  patients  in  the  least  pronounced  form 
of  the  disorder  appear  only  as  abnormally  bright  and 
quick-witted;  their  mental  action  is  exalted,  but  not 
entirely  beyond  their  control,  and  their  manner  and 
behavior  indicate  exaggerated  self -consciousness,  with 
a  usually  hilarious  and  mischievous  tendency.  The 
higher  inhibitions  are,  as  a  rule,  more  or  less  in  abey- 
ance, the  moral  sense  in  particular,  and  while  the 
patient's  reasoning  powers  may  appear  greatly  exalted, 
his  memory  enhanced,  and  his  faculties  for  work  in- 
creased, there  is  generally  in  these  cases  such  lack  of 
good  judgment  and  of  reliability  that  performance  is 
far  below  promise  as  regards  any  useful  outcome  of  the 
energies,  and  these  are  not  infrequently  badly  mis- 
directed in  a  moral  point  of  view.  These  are  cases 
that  in  their  mildest  type  may  not  be  taken  for  insane 
at  all,  but  merely  considered  as  especially  brilliant 
individuals,  even  more  intellectually  endowed  than 
ordinary  mortals.  There  is  generally,  however,  some- 
thing inconsistent  and  foolish  in  their  acts,  and  their 
self -feeling  is  so  pronounced  that  their  mental  morbidity 
is  sooner  or  later  detected.  Usually  this  is  early  mani- 
fest, and  perhaps  in  the  majority  of  cases  isolation  is 
resorted  to.  We  say  perhaps,  because  we  have  no 
statistics  as  to  the  frequency  of  this  condition;  it  cer- 
tainly comes  more  rarely  under  the  observation  of 
asylum  physicians  than  the  typical  maniacal  frenzy 
or  acute  mania  properly  so  called.  It  is  possible  that 
the  mildest  forms  occur  more  frequently  than  is  sup- 
posed, and  being  transitory,  they  pass  off  without 
attracting  attention  other  than  to  give  the  subject  a 
reputation  for  being  of  unequal  capacity  and  disposi- 
tion, or  subject  to  "  odd  spells."     When  it  affects  con- 


mania;  hypomania.  323 

duct  decidedly,  as  is  sometimes  the  case,  it  forms  what 
has  been  called  the  insanity  of  acts;  another  type  of 
this  mania  sine  delirio  that  is  hardly  yet  fully  recognized. 
There  is  reason  to  think  that  a  condition  of  this  general 
type  may  sometimes  become  chronic,  as  it  were ;  in  one 
case  known  to  the  writer  the  individual  subject  to  this 
condition  found  a  means  of  sobering  himself  by  stimu- 
lation, and  became  a  habitual,  almost  constant,  drinker, 
thus  undoubtedly  shortening  his  life  materially.  When 
to  a  certain  extent  under  the  influence  of  liquor,  he  was 
a  sober  rational  individual;  when  without  liquor,  he 
was  very  noticeably  nighty  and  erratic  in  speech, 
manner,  and  acts,  though  witty  and  brilliant.  As  he 
himself  remarked,  he  was  never  sober  unless  he  was 
drunk,  and  was  always  drunk  when  he  was  sober. 

The  involvement  of  the  ethical  impulse  varies  much 
in  these  cases,  though,  as  stated,  there  is  generally 
some  deterioration.  In  some  cases  it  is  very  pro- 
nounced, while  the  intellect  is  unimpaired,  or  its  powers 
apparently  enhanced.  This  constitutes  one  form  of 
the  so-called  moral  insanity,  and  a  very  typical  one. 
In  fact,  a  large  proportion  of  the  degenerative  in- 
sanities can  be  included  in,  or  are  closely  allied  to, 
these  milder  types  of  recurrent  degenerative  mania. 

Every  gradation  may  exist  between  the  acute  mania 
first  described  and  hypomania.  The  degree  of  excite- 
ment varies  widely,  as  does  also  the  self-control  and 
the  ethical  and  intellectual  impairment.  Some  pa- 
tients show  a  very  marked  degree  of  motor  excite- 
ment ;  while  still  comparatively  rational,  they  want  to 
do  the  work  of  two,  and  succeed  to  a  large  extent,  with- 
out apparently  suffering  undue  fatigue.  In  these 
milder  forms  the  bodily  symptoms  are  usually  very 
much  less  marked,  the  sleep  is  less  often  disturbed,  the 
appetite  is  more  regular,  the  patient  may,  in  fact,  be 
apparently  in  robust  health,  but  there  are  apt  to  be 
some  abnormalities  of  sensibility ;  there  is  less  sense  of 


324  DEGENERATIVE    INSANITIES. 

fatigue  than  normally,  for  example,  and  there  may  be 
other  physical  signs,  such  as  some  digestive  disturb- 
ances, constipation,  abnormal  appetite,  etc.,  and  mas- 
turbation is  frequently  excessive. 

The  course  and  duration  of  acute  mania  and  hypo- 
mania  are,  as  a  general  rule,  much  the  same ;  both  have 
alike  a  tendency  to  recovery.  Simple  acute  mania 
may  last  from  a  few  days  or  weeks  to  several  months 
or  even  longer,  but  the  average  duration  is  under  six 
months.  Attacks  of  hypomania  are,  in  our  experience, 
even  shorter  on  the  average,  but  occasionally  we  meet 
with  cases  of  very  long  duration,  in  which  the  condi- 
tions seem  to  have  become  chronic  without  at  least 
any  rapid  deterioration  mentally.  When  ordinary 
acute  mania  passes  into  the  chronic  condition,  which 
is  indicated  by  a  more  moderate  degree  of  excitement, 
there  is  generally  a  marked  mental  deterioration  and 
some  delusive  tendencies,  and  an  improvement  in 
nutrition  and  in  the  bodily  symptoms.  The  secondary 
condition  is  properly  a  terminal  dementia,  colored  a 
little  by  the  special  degenerative  defects  that  under- 
laid the  original  disorder.  This,  however,  is  the  ex- 
ceptional outcome  in  the  original  attack ;  the  usual  rule 
is  the  more  or  less  gradual  quieting  down  of  the  excite- 
ment, the  more  normal  ideation,  and  return  to  the 
normal  condition.  In  many  cases  of  this  form  of  in- 
sanity the  return  to  reason  is  abrupt,  the  cure  being 
apparently  complete  in  a  few  hours  or  days.  In  rare 
instances  the  excitement  may  continue  with  remissions 
for  over  a  year,  and  recovery  from  the  attack,  with 
possible  defect,  then  occur.  Commonly  the  earlier, 
single  attacks  of  mania  leave  less  of  the  mental  impair- 
ment than  might  be  expected  from  the  intensity  of  the 
symptoms,  but  their  frequent  repetition  is  finally 
attended  with  more  or  less  pronounced  psychic  dete- 
rioration. The  recurrence  may  be  long  delayed;  in 
fact,  it  is  not  an  absolute  certainty  in  any  case,  but  it 


MANIA PATHOLOGIC    ANATOMY  J    DIAGNOSIS.       325 

is  so  much  the  rule  that  it  may  be  confidently  looked 
for  to  occur  sooner  or  later.  In  most  cases  the  natural 
physical  exhaustion  after  an  acute  attack  is  the  most 
apparent  serious  consequence  left  on  the  return  to 
reason,  but  the  physical  recovery  usually  quickly 
follows  mental  improvement. 

Death  is  exceptional  as  a  result  of  acute  mania,  but 
it  may  occur  from  the  exhaustion  of  the  intense  and 
continued  bodily  and  mental  strain  alone.  More  com- 
monly it  is  the  result  of  some  accidental  intercurrent 
complication,  most  commonly  in  the  lungs,  but  some- 
times sepsis  from  injuries  which  these  patients  are 
liable  to  receive  and  which  are  sometimes  difficult  to 
properly  treat.  Infection  is  not  always  possible  to 
avoid,  and  may  have  already  occurred  before  the 
patient  comes  under  any  proper  care. 

The  patient's  recollections  of  the  attack  after  re- 
covery are  apt  to  be  more  or  less  confused  in  the 
severer  cases,  at  least  for  the  periods  of  highest  excite- 
ment, but  there  may  be  quite  complete  memory  of  the 
leading  events  of  the  larger  part  of  the  time.  In  the 
milder  forms  of  hypomania  there  is,  of  course,  no 
particular  defect  in  this  regard. 

Pathologic  Anatomy. — In  the  few  instances  that 
come  to  autopsy  there  are,  as  a  rule,  no  characteristic 
macroscopic  lesions  found.  Some  hyperemia  is  com- 
monly met  with  of  the  meninges  of  the  brain,  but  not 
much  more.  In  the  older  and  long-continued  cases  and 
after  many  recurrences  there  may  be  more  marked 
changes,  corresponding  to  those  of  the  terminal  de- 
mentia, to  which  these  cases  are  tending.  In  hypo- 
mania,  so  far  as  anything  at  all  has  been  observed,  it 
is  only  a  lesser  degree  of  hyperemia  to  that  seen  in 
acute  mania. 

Diagnosis. — The  forms  of  mental  disorder  with 
which  mania  is  especially  liable  to  be  confused  are  the 
agitated  forms  of  acute  confusional  insanity,  and  this 


326  DEGENERATIVE    INSANITIES. 

has  been  already  noticed,  to  some  extent,  in  speaking 
of  that  species  of  mental  disorder.  The  absence  of 
hallucinations  characteristic  of  confusional  disorder, 
the  occurrence  of  the  attacks  without  such  adequate 
cause  as  in  the  latter,  the  marked  ideational  excite- 
ment instead  of  the  confusional  delirium,  which 
present  quite  a  different  picture,  are  the  most  striking 
points  of  difference  noticeable  in  the  greater  number 
of  cases.  The  physical  condition  of  the  patient  is  also 
to  some  extent  a  guide ;  the  loss  of  the  fatigue  sense  is 
more  prominent;  the  motor  excitement  has  also  its 
special  character;  it  is  more  purely  motor,  and  not  so 
dominated  by  hallucinations  or  delusions.  In  those 
cases  where  the  onset  or  the  disappearance  is  sudden, 
these  also  are  characteristic.  If  one  bears  in  mind  the 
chief  features  of  the  two  disorders,  the  diagnosis  will 
not  generally  be  very  difficult  to  any  acute  observer. 

There  are  certain  phases  of  pubescent  insanity,  the 
excited  stage  of  the  so-called  catatonic  insanity  in 
particular,  that  have  some  resemblance  to  this  form, 
and  may  under  certain  conditions  possibly  lead  to 
confusion.  In  the  well-developed  pubescent  type, 
however,  there  is  a  pronounced  element  of  dementia  that 
is  wanting  in  ordinary  cases  of  mania,  to  say  nothing 
of  the  special  characteristics  of  verbigeration  and 
muscular  tonicity  which  may  be  manifest  to  some 
extent  even  in  the  excited  stage. 

The  early  stages  of  paretic  dementia  are  another 
possible  source  of  diagnostic  error,  more  commonly 
simulating  the  milder  than  the  severer  types  of  mania. 
There  may  be  a  similar  disordered  ideation,  and,  still 
more,  abnormalities  in  the  affective  sphere  and  moral 
lapses.  There  is  commonly,  however,  in  paresis  an  ex- 
travagance and  a  delusional  tendency  that  are  hardly 
characteristic  of  mania,  and  close  observation  will  often 
reveal  physical  signs  at  this  stage  that  betray  the 


MANIA PROGNOSIS.  327 

nature  of  the  disease.     A  little  longer  observation  will 
make  the  diagnosis  certain. 

Prognosis. — The  prognosis  of  mania  as  far  as  the 
earlier  single  attacks  are  concerned  is  generally  good. 
Indeed,  it  is  rarely  otherwise  under  proper  care.  The 
recovery  may  be  delayed  for  months,  but  in  true  acute 
mania  it  is  to  be  confidently  expected.  Some  attacks 
are  over  in  a  few  days.  As  regards  the  prospect  of 
future  freedom  from  attacks,  on  the  other  hand,  it  is 
not  good;  hence  the  propriety  of  the  term  recurrent 
insanity  that  we  have  applied  to  it.  According  to 
Kraepelin,  who  has  given  the  point  very  particular 
attention,  in  a  thousand  cases  which  he  was  able  to 
trace  in  their  future  history,  in  only  one  was  there  no 
recurrence  of  the  disorder.  In  all  the  others  sooner 
or  later  other  maniacal  attacks  or  circular  insanity 
appeared.  Somewhat  similar  testimony  has  been  given 
by  others  who  have  specially  studied  this  phase  of  the 
question.  It  is  true,  as  he  says,  the  interval  between 
the  attacks  may  be  long,  as  much  as  ten  years,  or  more, 
but  he  finds  it  usually  much  less.  We  are,  in  his  view, 
to  estimate  the  single  or  rare  attacks  in  this  disorder  at 
about  the  same  pathologic  value  as  the  rare  and  isolated 
attacks  of  epilepsy  in  certain  patients  with  an  epileptic 
constitution ;  they  are  only  very  marked  evidences  of  the 
continuously  existing  underlying  constitutional  degen- 
eracy. We  have  not  ourselves  made  statistic  studies  of 
the  recurrences  in  true  mania,  but  our  experience  has 
been  such  as  to  make  it  seem  highly  probable  that  KraeT 
pelin,  Van  Taalman  Kip,  and  others  who  have  main- 
tained that  recurrences  are  nearly  constant  in  this 
form,  are  not  far  from  correct.  That  there  may  be 
instances  where  only  a  single  attack  occurs  is  probable 
enough ;  the  same  is  true  of  epilepsy,  that  other  striking 
manifestation  of  cortical  instability.  It  is  possible, 
moreover,  that  in  some  instances,  probably  rare,  the 
tendency  may  be  outgrown  during  the  long  time  of 


328  DEGENERATIVE    INSANITIES. 

freedom,  and  a  practically  perfect  cure  occur.  Such 
cases,  nevertheless,  do  not  affect  the  general  correct- 
ness of  the  view  that  there  is  in  this  disorder  a  profound 
degenerative  constitutional  defect. 

Recovery  with  mental  deterioration  or  defect  is  less 
frequent  in  this  form  of  insanity  after  first  attacks 
than  in  primary  confusional  insanity.  The  disorder 
seems  to  leave  less  permanent  damage  than  is  often 
the  case  with  the  acquired  insanities,  and  it  is  remark- 
able sometimes  how  little  apparent  intellectual  defect 
is  left  after  an  attack.  There  is  more  apt  to  be  some 
moral  deterioration  left,  for  a  while  at  least,  and  this 
is  sometimes  rather  striking.  The  patients  often  have 
a  more  or  less  complete  recollection  of  their  acts,  and  a 
certain  conscious  taint  from  the  lost  higher  inhibitions 
is  apt  to  remain.  A  clergyman,  for  example,  who  was 
seized  during  the  excitement  of  a  revival,  became  ex- 
ceedingly profane  and  obscene  during  the  height  of  his 
disorder,  and  after  his  recovery,  while  apparently 
normal  in  all  other  respects,  appeared  to  have  for  a 
time  no  special  religious  sympathies  or  tendencies  what- 
ever. This  was  rather  an  extreme  example,  but  in  a 
lesser  degree  the  same  phenomenon  is  not  infrequently 
observed. 

After  many  repeated  attacks  general  mental  dete- 
rioration is  the  rule,  and  this  is  the  more  probable  and 
rapid  in  appearance  if  the  attacks  are  severe  and  the 
intervals  short.  It  may  also  follow  a  single  very  severe 
or  prolonged  attack,  and  while  recovery  may  be  ap- 
parently complete,  there  may  still  remain  for  a  time 
some  impulsive  tendencies  that  show  a  lack  of  perfect 
function  in  the  higher  mechanisms  of  the  brain. 

As  said  before,  death  is  a  comparatively  rare  termina- 
tion of  an  acute  maniacal  attack.  It  may  occur,  how- 
ever, from  general  exhaustion  by  the  intense  mental 
and  motor  activities  in  very  severe  cases,  and  more 
frequently  from  some  complicating  or  intercurrent  dis- 


MANIA TREATMENT.  329 

order.  When  we  consider  what  in  some  exceptional 
cases  these  patients  go  through,  even  with  the  best  of 
care  and  other  judicious  treatment,  it  is  not  remarkable 
that  fatal  exhaustion  sometimes  occurs,  the  more 
specially  when  it  is  remembered  that  in  many  cases  in 
the  past,  and  sometimes  even  now,  the  exposure  and 
strain  undergone  are  almost  enough  to  apparently 
break  down  the  strongest  constitution. 

Individuals  certainly  run  some  risk,  and  the  chance 
of  complicating  disease  from  exposure  or  overstrain 
must  always  be  kept  in  mind  in  the  acute  form.  An 
important  symptom  of  recovery  is  increase  in  the  body- 
weight,  occurring  together  with  mental  improvement. 
This  has  possibly  been  overestimated,  but  it  is  still  a 
point  worthy  of  close  attention. 

The  treatment  of  acute  mania  is  mainly  along  seda- 
tive lines;  removal  of  all  irritating  or  exciting  factors, 
internal  as  well  as  external.  Removal  from  home  and 
accustomed  surroundings  is  imperative,  and  the  change 
to  the  atmosphere  of  a  well-ordered  asylum  or  hospital 
has  in  itself  a  most  valuable  therapeutic  effect.  One 
of  the  first  essentials  is  to  attend  to  the  condition  of  the 
bowels,  which  in  the  majority  of  cases  are  constipated; 
to  do  away  with  any  auto-intoxication  that  may  exist ; 
and  also,  we  believe,  to  put  an  end  to  a  possible  reflex 
irritation  that  is  mechanically  set  up  by  an  overloaded 
colon.  Soon  after  reception,  it  is  a  good  practice  to 
give  a  warm  bath,  prolonged  for  twenty  minutes 
or  over,  followed  by  a  thorough  irrigation  of  the 
lower  bowel,  and  then  to  give  a  full  meal  of  milk 
and  eggs  beaten  up  together  or  of  meat  broth,  and 
put  the  patient  to  bed.  If  this  can  be  timed  so  as  to 
have  this  occur  near  the  regular  hour  for  sleep,  so  much 
the  better.  The  patient  will  often  go  at  once  to  sleep 
and  get  a  good  night's  rest.  A-Vnen  the  excitement  is 
not  too  intense,  this  treatment  can  be  continued,  the 
patient  being  kept  in  bed  under  constant  watch  for 


330  DEGENERATIVE    INSANITIES. 

several  day^  or  a  week  till  the  excitement  has  decreased. 
If  sleep  does  not  come  easily,  recourse  can  be  had  to 
drugs;  the  bromid  of  sodium  alone  in  30-  or  40- 
grain  doses  in  water  may  suffice  in  some  cases;  in 
others  sulfonal,  15-30  grains  (1.0-2.0  gm.),  or  hydro- 
bromate  of  hyoscin,  T|g-  grain  (0.0006  gm.)  or  less 
hypodermically,  may  be  required.  The  latter,  how- 
ever, is  of  less  value  as  a  hypnotic  than  as  a  sedative 
to  the  motor  excitement,  and  its  use  may  better  be 
deferred  till  daytime  if  needed  for  this  purpose.  A 
combination  of  hypnotics  is  sometimes  useful,  given 
not  together,  but  at  timed  intervals  apart,  so  as  to 
obtain  the  best  effects.  For  example,  sulfonal,  whose 
action  is  slow,  taken  a  little  while  before  bedtime ;  and 
a  dose  of  some  more  rapid  hypnotic,  like  chloralamid, 
immediately  on  retiring.  One  of  these  puts  the  patient 
to  sleep  and  the  other  keeps  him  from  waking  as  soon 
as  the  effects  of  the  last  given  dose  have  worn  off. 
Chloral  was  formerly  the  standby  as  a  hypnotic,  either 
alone  or  in  combination  with  other  sleep-producing 
and  sedative  drugs,  such  as  the  bromids,  hyoscyamus, 
conium,  etc.,  but  of  late  years  its  use  has  very  largely 
decreased.  If  employed,  it  should  be  in  very  moderate 
doses,  as  the  large  doses  formerly  used  were  sometimes 
found  dangerous,  and  it  often  happens  that  a  careful 
and  complete  diagnosis  of  the  heart  condition,  which 
is  an  important  matter  with  the  use  of  this  drug,  cannot 
always  be  satisfactorily  made  in  a  case  of  excited 
mania.  In  extreme  cases  it  is  very  difficult  to  ad- 
minister hypnotics  by  the  mouth,  and  hyoscin  hypo- 
dermically will  have  to  be  used.  Any  hypnotic  that  is 
used  should  be  carefully  watched  as  to  its  effects,  and 
it  will  often  be  found  that  a  prolonged  warm  bath, 
with  perhaps  cold  applications  to  the  head,  is  a  far 
better  sleep-producer  than  any  drug. 

Good  nourishment  is   one   of  the  most   important 
features  of  the  treatment  of  mania,  and  if  the  patient's 


MANIA — TREATMENT.  33 1 

bodily  strength  can  be  kept  up,  the  motor  excitement 
is  of  comparatively  secondary  importance.  The  tend- 
ency of  most  attacks  is  toward  recovery  in  time,  and 
nature  only  needs  assistance.  These  patients  need 
attention ;  their  bodily  functions  must  be  looked  after ; 
to  be  kept  warm,  which  is  not  always  an  easy  task; 
to  be  protected  from  exposure,  and  so  far  as  possible 
to  have  every  source  of  irritation  and  excitement  re- 
moved. Sometimes  it  is  well  to  let  them  work  off 
some  of  their  excitement  by  movement ;  certain  cases 
appear  to  do  best  in  this  way.  Mechanical  restraint, 
so  much  used  formerly,  is,  as  a  rule,  irritating  to  these 
cases,  and  its  employment  should  be  avoided  as  far  as 
possible.  In  the  best  asylums  it  is  almost  entirely 
dispensed  with. 

The  milder  forms  of  mania — hypomania,  or  mania 
sine  delirio,  reasoning  mania,  insanity  of  acts,  and 
maniacal  moral  insanity — call  for  moral  treatment 
more  than  medicine.  Some  legal  restraint  is  advisable 
when  it  can  be  authorized,  and  a  firm  but  just  and 
kindly  control  is  always  best.  These  patients  are  con- 
scious of  their  acts  and  of  the  legal  irresponsibility  to  a 
very  large  extent,  and  are  frequently  hard  to  manage, 
but  they  respect  a  power  which  they  know  they  will  have 
to  obey.  The  hospitals  for  the  insane,  with  their 
facilities  for  classification  by  numerous  wards,  and  their 
regulated  mode  of  life  and  means  of  keeping  facilities 
for  mischief,  etc.,  out  of  the  way,  are  generally  able 
to  control  these  cases,  though  it  may  be  difficult  at 
times.  According  as  the  case  approaches  the  type  of 
acute  mania  the  usual  medicinal  and  other  measures 
come  in  play,  and  in  all  cases  attention  to  the  condition 
of  the  bowels,  the  nutrition,  and  sleep  is  essential. 

Before  leaving  the  subject  of  mania  it  may  be  stated 
that  there  are  many  cases  in  which  it  occurs  in  a  mixed 
form  or  superimposed  upon  some  other  type  of  insanity. 
It   may  and   sometimes   does   complicate  an  already 


332  DEGENERATIVE    INSANITIES. 

existing  paranoiac  insanity  and  also  certain  forms  of 
imbecility.  Acute  confusional  insanity,  the  form  that 
has  in  the  past  been  most  mistaken  for  it,  may  in  a 
degenerate  have  a  maniacal  tinge,  thus  complicating 
the  diagnosis.  Ordinarily,  however,  the  tumultuous 
ideation  and  illusions  of  the  one  are  fairly  well  dis- 
tinguishable from  the  confused  hallucinatory  delirium 
of  the  other,  in  spite  of  the  common  characters  they 
may  appear  to  possess. 


CIRCULAR  INSANITY. 

By  circular  insanity  we  understand  a  condition  of 
degenerative  mental  disease  consisting  essentially  of 
alternating  attacks  of  mania  and  of  depression,  with 
or  without  an  intervening  state  of  normal  mental 
functioning.  The  difference  between  circular  insanity 
and  mania  is  a  clinical  one,  and  also  to  some  extent  an 
arbitrary  one.  In  mania  we  often  have,  and  some 
authorities  consider  it  the  rule,  a  brief  period  of  depres- 
sion preceding  the  excitement,  and  in  circular  insanity 
one  or  the  other  phase  may  be  abbreviated  or  unduly 
extended,  so  that  gradation  between  the  two  is  possible 
and  is  sometimes  observed.  It  has  been  already  re- 
marked that  some  cases  of  apparent  periodic  melan- 
cholia are  really  cases  of  circular  insanity,  with  a  very 
short  maniacal  phase. 

Circular  insanity,  while  it  has  been  considered  a  com- 
paratively rare  affection,  is,  if  we  include  all  its  grades 
of  severity,  a  rather  common  form  of  mental  disorder. 
Mild  cases  are  often  met  with  that  are  not  recognized 
by  the  laity,  and  which  go  about  their  ordinary  avoca- 
tions without  exciting  serious  suspicion  of  the  mental 
soundness.  They  are  regarded  as  eccentric  and  sub- 
ject to  moods,  but  their  general  self-control  and  reason- 
ing power  save  them  from  being  counted  popularly 
amongst  the  insane.     It  is  only  when  the  disease  is  so 


CIRCULAR    INSANITY.  333 

well  developed  that  the  patient  is  no  longer  master  of 
himself  that  it  is  generally  recognized. 

Etiology. — What  has  been  said  as  to  the  etiology  of 
mania  applies  equally  well  to  the  form  under  considera- 
tion. The  most  prominent  and  important  element,  and 
it  is  commonly  said  that  it  is  present  here  even  more 
often  than  in  other  insanities,  is  a  homologous  heredity. 
We  cannot  say  that  this  has  been  notably  the  case  in  our 
observations;  any  one  form  of  degenerative  heredity 
has  appeared  to  be  as  relatively  frequent  as  any  other. 
In  many  cases  no  apparent  cause  is  observable,  or  the 
first  attack  may  follow  any  one  of  the  ordinary  disturb- 
ing factors — shock,  traumatism,  involution,  etc.  It  is 
often  said  to  be  more  frequent  in  females  than  in  males, 
a  statement  that  is  probably  more  true  of  the  well- 
developed  forms  than  of  all  cases  taken  together.  The 
milder  walking  cases  of  circular  insanity  have,  in  our 
extra-asylum  experience  with  the  disease,  occurred 
more  frequently  among  males  than  in  the  other  sex. 
The  disorder  is  more  especially  liable  to  first  appear  in 
the  third  or  fourth  decade  of  life,  but  it  may  occur  at 
any  age.  One  of  the  most  well-marked  cases  we  have 
seen  was  in  a  man,  eighty  years  of  age,  who  had  been 
insane  in  one  way  or  another  for  many  years.  It  may 
have  existed  in  a  milder  form  for  a  long  time  before  it 
finally  is  recognized  by  the  patient's  friends  as  insanity, 
but  not  every  subacute  case  ends  this  way. 

Symptomatology. — It  is  generally  difficult  to  say 
under  which  phase  the  first  beginnings  of  circular  in- 
sanity appear ;  often  the  patient  has  alternating  spells 
of  excitement  and  depression,  gradually  increasing  in 
severity,  for  some  time  before  the  changes  are  recog- 
nized as  actual  mental  disorder.  In  a  very  large  pro- 
portion of  cases  the  maniacal  phase  of  circular  in- 
sanity is  of  the  milder  hypomaniac  type,  while  the 
depressed  stage  may  be  more  marked,  and  the  pa- 
tient's   case    is    diagnosed    at  [first    as    melancholia. 


334  DEGENERATIVE    INSANITIES. 

There  is  no  regular  rule,  however;  there  may  be  an 
aggravated  maniacal  condition  that  is  first  recognized 
as  abnormal,  but  more  commonly,  we  think,  the 
melancholic  phase  is  first  prominent  enough  to  betray 
the  patient's  mental  aberration.  In  this  depressed 
phase,  which  may  appear  suddenly  or  gradually,  the 
patient  is  often  a  striking  example  of  pure  emotional 
depressive  insanity.  There  are  no  delusions ;  there  is 
full  self -consciousness  of  his  condition;  he  is  simply 
though  acutely  depressed,  without  energy  or  ambi- 
tion, and  existence  is  painful,  though  these  cases  are 
comparatively  seldom  suicidal  in  their  tendency. 
Sometimes  they  are  querulous  and  willing  to  state 
their  complaints,  but  this  is  not  the  rule.  There  are 
comparatively  seldom  the  active  self-accusatory  de- 
lusions of  ordinary  melancholia,  and  if  these  do 
appear,  it  is  generally  at  a  well-advanced  stage  of  the 
disease.  There  may  be  self-accusations  and  feelings 
of  unworthiness,  but  they  are  less  prominent  or  frequent 
than  in  ordinary  melancholia.  The  more  common 
tendency  in  the  severer  types  of  the  melancholic  stage 
of  circular  insanity  is  toward  an  apparent  stuporous 
condition;  the  mental  and  physical  depression  may 
appear  extreme ;  the  patient  seems  in  a  raptus  melan- 
cholicus,  unmindful  of  all  about  him,  neglecting  to 
answer  the  calls  of  nature  and  soiling  his  garments, 
eating  irregularly  or  refusing  food,  but  allowing  himself 
to  be  fed  without  resistance,  and  occasionally  showing 
the  catatonic  muscular  rigidity  to  a  greater  or  less 
extent.  Sleep  is  broken  and  scanty,  and  the  general 
physical  condition  rapidly  deteriorates.  The  most 
typical  melancholia  of  circular  insanity,  however,  in 
our  opinion,  is  a  milder  type  than  the  above ;  there  is  a 
moody  silent  type  of  depression  which  is  not  always 
acutely  melancholic,  a  sort  of  general  psychic  inhibition 
with  more  or  less  pronounced  emotional  tinge.  Some- 
times the  patients  appear  more  moody  and  sulky  than 


CIRCULAR    INSANITY.  335 

melancholy,  or  simply  torpid  both  mentally  and 
physically.  In  some  cases,  in  fact,  where  the  excite- 
ment is  intense  in  the  maniacal  phase,  and  the  cycle 
is  brief,  the  depressed  phase  sometimes  appears  to  be 
only  the  mental  and  physical  reaction,  without  any 
really  marked  emotional  tinge  whatever.  The  patient 
sits  or  lies  quiet  and  indifferent  to  all  around  him;  he 
may  be  moody  and  inactive,  apparently  dozing  much 
of  the  time.  When  aroused,  he  will  perhaps  briefly 
answer  questions ;  he  goes  to  his  meals  and  eats  indif- 
ferently what  is  given  him;  he  may  need  attention  to 
make  him  take  ordinary  care  of  himself,  to  answer 
calls  of  nature,  and  keep  out  of  harm  generally.  In 
other  cases  the  patients  look  out  for  themselves  fairly 
well,  act  as  if  they  realized  their  surroundings,  but  are 
simply  mentally  and  physically  inactive,  with  just  a 
tinge  apparently  of  emotional  depression.  In  the 
great  majority  of  cases  of  circular  insanity,  in  our  obser- 
vation, the  depressed  stage  has  a  certain  peculiar  char- 
acter, different  from  that  of  ordinary  melancholia,  and 
resembling  more  the  semi-stuporous  phase  of  confu- 
sional  insanity,  but  usually  without  the  confusional 
and  hallucinatory  delusive  character  of  the  latter. 
It  is  more  a  pure  mental  and  physical  inhibition  with 
a  more  or  less  evident  affective  depression.  This  is 
not  so  pronounced  as  to  be  generally  diagnostic  in 
individual  cases,  but  the  general  impression  left  by 
observation  of  a  number  of  cases  is  of  this  nature. 

In  certain  cases  where  the  depressed  stage  is  more 
prominent  than  the  excited  stage,  the  resemblance  to 
ordinary  melancholia  is  more  apparent,  but  here  also 
the  apparent  semi-stuporous  condition  is  apt  to  pre- 
dominate. Delusions  of  unworthiness  may  exist,  and 
even  hallucinations,  but  these  latter  are,  in  our  ex- 
perience, rare.  A  very  marked  predominance  of  the 
depressed  stage  and  corresponding  shortening  of  the 
other  will  indicate,  or  at  least  suggest,  a  neurasthenic 


336  DEGENERATIVE    INSANITIES. 

or  exhaustion  element  in  the  case.  The  more  closely 
the  mental  state  approaches  ordinary  melancholia,  the 
closer  the  resemblance  also  in  the  physical  condition — - 
the  disturbances  of  sleep  and  digestion,  the  irregular 
or  scanty  appetite,  the  loss  of  weight,  etc. ;  these  occur 
in  most  of  the  depressed  phases,  but  are  less  marked 
in  the  milder  cases. 

The  excited  or  maniacal  stage  varies  widely  in  its 
type.  As  already  remarked,  the  hypomaniac  form  is 
probably  the  most  common,  but  this  varies  much  in 
its  intensity,  from  an  apparently  mild  intellectual  ex- 
altation to  a  most  troublesome  type  of  insanity  of  acts 
and  moral  insanity.  The  patient  may  indulge  in  the 
most  outrageous  extravagances  of  conduct,  he  may 
be  apparently  inspired  by  the  very  spirit  of  mischief 
and  malice,  and  yet  be  so  clear-headed  as  to  be  able  to 
convince  a  judge  or  jury  that  he  is  perfectly  sound 
mentally,  and  to  avail  himself  of  every  possible  legal 
technicality  in  securing  or  insuring  his  liberty.  He 
may  apparently  fully  appreciate  his  own  acts  and 
recognize  their  nature,  but  be  to  all  appearances  per- 
fectly unprincipled  as  regards  them,  and  have  sufficient 
cunning  and  self-control  to  keep  himself  clear  of  legal 
consequences.  A  young  woman,  whose  sole  object 
during  this  stage  seemed  to  be  to  keep  the  ward  in 
trouble  and  effect  as  much  destruction  of  property  as 
was  within  her  ability,  used  to  say  she  was  not  insane, 
she  was  just  "  mean,"  and  knew  it  as  well  as  anybody. 
Another  patient,  a  lawyer,  who  varied  his  amusements 
from  threatening  and  attacking  attendants  and  smash- 
ing windows  to  writing  elaborate  petitions  for  habeas 
corpus  for  other  patients,  was  always  ready  to  claim 
all  his  advantages  from  his  legal  disabilities  in  excusing 
his  conduct  when  he  cared  to  do  so.  These  patients 
are  very  difficult  to  manage  at  times,  their  moral 
deterioration  with  their  perfect  mental  self-conscious- 
ness seriously  aggravating  the  situation.     If  at  large, 


CIRCULAR    INSANITY.  337 

they  are  liable  to  commit  minor  offenses,  to  disgrace 
themselves  or  their  families,  and  their  erotic  tendencies 
are  sometimes  especially  manifested  by  improprieties, 
and  sometimes,  with  women,  by  seriously  compromis- 
ing behavior.  Not  every  case,  however,  shows  this 
pronounced  moral  defect;  in  some  mild  cases  the  ex- 
citement is  worked  off  by  legitimate  occupation,  as  in 
the  case  of  a  business  man  whose  depressed  stage  was 
mild  and  not  altogether  disabling,  and  who  during 
the  excited  stage  was  a  very  successful  and  exceedingly 
active  commercial  traveler.  In  other  cases  the  excited 
stage  has  many  of  the  characters  of  the  grand  delirium 
of  paresis,  and  this  may  lead  to  errors  of  diagnosis,  the 
more  probable  since  an  irregular  circular  type  of 
paresis  is  sometimes  recognized.  Delusions,  while  not 
the  rule,  sometimes  are  detectable,  and  may  be  fixed 
and  prominent.  The  pronounced  maniacal  type  of  the 
disorder  is,  however,  very  distinctive,  and  readily 
separates  it  from  ordinary  paranoiac  types.  A  patient 
in  our  care  maintained  that  he  was  the  Messiah;  the 
delusion  was  ever-present,  and  dominated  all  his  ideas, 
though  his  exalted  religious  notions  did  not  prevent 
a  very  decided  moral  deterioration  that  coexisted  with 
it.  He  was  a  considerable  portion  of  the  time  in  a 
rage  at  some  person  for  not  duly  recognizing  his  Mes- 
siahship,  and  was  not  choice  in  his  language  in  ad- 
dressing him.  In  still  other  cases  where  the  mania 
is  yet  more  pronounced,  the  mental  and  bodily  activity 
is  incessant ;  these  are  generally  short  cycle  cases.  One 
patient  of  this  kind  whose  maniacal  phase  lasted  about 
ten  days  apparently  never  slept  during  this  period; 
was  continuously  engaged  in  endeavoring  to  destroy 
his  clothing  and  articles  about  him  during  the  day, 
and  would  spend  his  nights  making  a  sort  of  flour  out 
of  the  straw  of  his  mattress.  He  was  only  manageable 
when  his  activities  could  be  diverted  in  some  such 
comparatively  harmless  way ;  a  tick  full  of  straw  would 


338  DEGENERATIVE    INSANITIES. 

thus  be  reduced  every  night  by  him  into  a  pile  of  fine 
chaff.  Still  another  case  would  talk  incessantly  for 
several  weeks  at  a  time,  day  and  night,  never  caught 
napping,  though  it  would  seem  impossible  he  could 
go  so  long  without  sleep.  In  both  these  extreme  cases 
the  depressed  stage  was  a  sort  of  semi-stupor,  and  the 
emotional  symptoms  were  not  very  noticeable. 

The  change  from  one  phase  to  another  in  some  in- 
stances is  very  abrupt;  it  may  occur  during  sleep,  the 
patient  going  to  bed  after  a  day  of  lively  maniacal  ex- 
citement, and  waking  the  next  morning  more  or  less 
intensely  depressed.  It  more  rarely  occurs  suddenly 
in  the  daytime.  The  separate  phases  may  be  of  vary- 
ing duration — days,  months,  or  years ;  but  the  average 
is  probably  considerably  under  a  year.  The  longer 
the  attack,  the  more  gradual  the  changes  and  the  more 
probable  the  occurrence  of  an  intermission  or  lucid 
interval  between.  This,  however,  is  by  no  means  con- 
stant, even  in  the  long  attacks,  and  in  many  instances 
each  stage  passes  gradually  into  the  other  without  any 
real  period  of  apparent  mental  soundness  between 
them.  In  still  others  the  depressed  may  pass  directly 
into  the  maniacal  phase,  or  vice  versa;  then  follow 
lucid  intervals,  and  this  cycle  repeats  itself  over  and 
over  again.  The  duration  of  the  normal  period  is  also 
very  variable;  frequently  it  is  very  short;  it  is  only 
seldom  that  it  is  long,  but  this  occasionally  happens, 
and  it  may  even  continue  for  such  a  period  as  to  con- 
stitute an  apparent  cure.  Indeed,  we  have  seen  cases 
go  through  two  or  more  cycles,  and  then  appear  to 
recover  and  remain  well  for  long  periods  of  time;  in 
fact,  as  long  as  they  have  been  under  observation. 
Whether  a  complete  cure  ever  occurs  is  exceedingly 
doubtful;  at  least,  understanding  by  such  a  complete 
transformation  to  the  normal  mental  condition  without 
special  liability  to  a  recurrence  of  the  disorder.  In  this  re- 
gard circular  insanity  and  mania  are  alike ;  both  are  of 


CIRCULAR    INSANITY.  339 

the  same  type  of  degenerative  psychoses.  The  two  dis- 
orders are  less  different  than  they  at  first  appear,  and 
merge  into  each  other  to  a  very  marked  extent.  This 
distinction  between  them  is,  as  already  said,  purely  a 
clinical  one,  and  of  the  two,  circular  insanity  is  prob- 
ably the  most  pronouncedly  and  typically  degenerative 
in  character. 

While  mental  deterioration  is  not  rapid  in  circular 
insanity,  as  a  rule,  the  tendency  is  gradually  toward 
terminal  dementia.  In  patients  who  have  long  been 
the  subjects  of  this  form  there  is  usually  a  very  well- 
marked  mental  aberration,  and  the  comparatively 
lucid  intervals  are  often  apt  to  be  so  short,  if  they  occur 
at  all,  as  to  be  hardly  observable.  Even  in  these  cases, 
however,  the  degree  of  dementia  is  not  so  decided  as 
in  many  other  forms  of  insanity.  Death  may  occur 
possibly  from  exhaustion  in  the  severer  attacks,  but 
this  is  rare;  usually  it  is  from  some  complicating  dis- 
order, rarely  from  suicide. 

The  pathologic  anatomy  is  practically  unknown  of 
the  milder  forms ;  when  an  autopsy  is  afforded  in  these, 
the  complicating  disorder  is  likely  to  be  responsible 
for  any  brain  changes  observed.  In  the  very  excited 
stage  we  will  probably  find  some  degree  of  cerebral 
hyperemia ;  otherwise,  no  constant  lesion  can  be  pred- 
icated. In  the  cases  of  long  duration  the  changes 
of  chronic  insanity  or  terminal  dementia  may  be  more 
or  less  apparent. 

The  diagnosis  of  circular  insanity  is  easily  made  after 
observation  of  one  or  more  of  its  cycles,  but  the  special 
phases  alone  may  be  readily  mistaken  for  some  other 
forms  of  mental  disorder.  The  maniacal  phase  may 
easily  be  taken  for  an  attack  of  simple  acute  mania, 
which  is  practically  the  same  thing  while  it  lasts.  It 
may  also  in  its  hypomaniac  type  be  confused  with  the 
early  stage  of  paresis,  but  in  the  latter  the  hypomania 
is  less  pure  and  mental  weakness  and  exalted  delusions 


34-0  DEGENERATIVE    INSANITIES. 

are  apt  to  be  pronounced.  It  is  only  in  those  cases 
where  a  degenerative  taint  underlies  the  paretic 
dementia — or,  stated  better,  the  latter  is  superposed 
upon  a  degenerate  constitution  and  the  toxic  and 
vesanic  forms  are  combined,  as  in  the  so-called  circular 
type  of  paresis — that  any  confusion  can  long  exist. 
The  physical  signs  of  paresis,  on  which  we  now  so  much 
depend  for  its  diagnosis,  are,  of  course,  wanting  in 
circular  insanity,  and  this  alone  will  sooner  or  later 
settle  the  question  in  ordinary  cases.  The  insanity  of 
pubescence  often  takes  on  a  double  form,  as  in  the  so- 
called  catatonia,  but  the  progress  to  dementia  is  rapid, 
and  the  characteristic  symptoms  of  muscular  tonicity, 
verbigeration,  the  absence  of  pure  maniacal  excitement, 
as  in  circular  insanity,  are  distinguishing  features  that 
reveal  the  true  nature  of  the  case  with  any  close,  con- 
tinued observation.  The  depressed  stage  is  easily 
mistaken  for  melancholia,  and  often  only  close  observa- 
tion, or  the  occurrence  of  the  cyclic  changes,  will  enable 
one  to  make  a  correct  diagnosis.  The  pure  simple 
depression  is  rather  characteristic,  and  to  one  who  is 
accustomed  to  these  cases,  something  may  be  some- 
times determined  by  this  and  some  other  features, 
hard  to  define  in  the  type  of  the  melancholia.  In 
those  cases  with  self-accusatory  tendencies  or  delu- 
sions of  unworthiness  the  diagnosis  in  this  stage  is 
difficult  and  almost,  or  quite,  impossible.  In  the 
stuporous  or  semi-stuporous  cases  there  may  be  con- 
fusion with  the  similar-appearing  forms  of  acute  con- 
fusional  insanity,  but  there  are  not  the  hallucinations 
or  the  confusion  so  typical  of  the  latter.  When  these 
cannot  be  determined  as  existing,  a  mistake  is  excus- 
able, till  on  the  further  development  of  the  case  its 
true  nature  is  apparent.  The  purely  apathetic  cases, 
where  the  patient  appears  to  be  only  reacting  from  the 
intense  excitement  of  the  acute  stage,  can  only  be 
confounded  with  certain  forms  of  dementia,  but  here 


CIRCULAR    INSANITY.  341 

the  cycle  is,  as  we  have  seen  it,  generally  so  brief  that 
any  continued  misunderstanding  of  the  case  is  prac- 
tically impossible. 

The  treatment  of  circular  insanity  may  be  summed 
up  in  a  few  words.  It  is  purely  symptomatic ;  the  case 
must  be  treated  as  each  emergency  indicates.  Seda- 
tives and  hypnotics  can  be  used  to  quiet  motor  rest- 
lessness and  secure  sleep,  and  moral  treatment,  in  the 
way  of  a  kindly  but  firm  control,  is  often  very  important 
in  the  hypomaniac  types.  During  the  depressed  stage 
the  usual  treatment  for  such  conditions  is  indicated, 
and  while  these  cases  are  probably,  as  a  rule,  less 
suicidal  in  their  tendency  than  is  the  case  in  ordinary 
melancholia,  they  should  be  carefully  watched  and 
guarded.  The  condition  of  the  bowels,  and  of  digestion 
and  nutrition  generally,  is  to  be  looked  after  carefully 
in  all  stages,  and  forced  feeding  may  be  occasionally 
required  in  extreme  cases.  By  attention  to  these 
matters  we  may  materially  modify  the  symptoms  and 
possibly  shorten  the  attacks  and  lengthen  the  lucid 
periods. 


CHAPTER  XVIII. 

DEGENERATIVE  INSANITIES  (Continued). 

PARANOIA. 

The  term  paranoia  as  commonly  used  has  rather  a 
wide  signification,  covering,  as  it  does,  a  wide  range  of 
conditions  characterized  especially  by  the  existence  of 
fixed  or  systematized  delusive  conceptions  without  any 
primary  or  conspicuous  involvement  of  the  emotional 
or  affective  faculties.  Various  authors  have  thus  used 
it,  including,  as  will  be  seen,  mental  conditions  ranging 
from  imbecility,  on  the  one  hand,  to  almost  perfect, 
though  in  some  directions  perverted,  intellection. 
Others  have  variously  modified  the  concept  and  have 
divided  it  up  in  groups,  according  as  it  it  accompanied 
with  degenerative  stigmata,  or  with  or  without  hal- 
lucinations. Some  extend  the  term  to  include  the 
secondary  delusional  insanities  already  mentioned  in 
connection  with  various  acute  primary  mental  derange- 
ments, and  which  will  be  noticed  more  fully  when  we 
come  to  speak  more  particularly  of  terminal  conditions 
of  mental  disease.  Some  authors  also  recognize  an 
acute  form  of  paranoia  which  will  be  discussed  later. 

Recognizing  all  these  facts  and  different  views  on 
the  subject,  it  is  evident  that  the  definition  of  what 
we  here  propose  to  understand  by  the  term  must  be 
fairly  stated  before  describing  the  condition.  We 
prefer  a  rather  comprehensive  definition  to  one  more 
definite  and  limited,  since  the  included  morbid  mental 
states  graduate  into  each  other,  and  therefore  our 
conception  of  paranoia  is  a  rather  broad  one.  We 
recognize,  however,  certain  well-marked  types,  widely 
differing  in  their  extremes,  yet  so  shading  into  each 

342 


paranoia. 


PARANOIA.  343 

• 

other  that  it  does  not  appear  best  to  consider  them  as 
absolutely  distinct,  or  to  give  them  distinctive  titles, 
except  as  varieties  of  the  same  condition.  We  do  not, 
moreover,  include  under  this  head  the  secondary 
delusional  insanities,  which  have  with  it  only  the 
common  symptoms  of  delusions  and  hallucinations. 
Acute  paranoia  is  not,  in  our  opinion,  to  be  considered 
as  a  distinct  form;  it  is  probably  a  brief  episodic 
derangement  of  a  degenerate  brain,  or  an  aberrant  form 
of  toxic,  pubescent,  or  other  insanity.  It  is  quite 
within  the  limits  of  possibility  for  the  symptoms  of 
delusional  mental  derangement  to  appear  temporarily 
in  a  predisposed  individual,  and  such  cases  are  some- 
times observed. 

We  here  include  under  our  general  designation  of 
paranoia  a  class  of  cases  that  resemble  the  type  in  some 
respects,  and  that  are  perhaps  commonly  included 
under  this  head,  but  that  differ  from  it  in  the  fact  that 
the  apparent  delusions  are  voluntarily  self-cultivated 
in  an  extremely  degenerative  organization,  where 
judgment  and  intellection  are  especially  weakened  by 
natural  defect,  and  which  is  more  closely  related  to 
imbecility  than  to  any  other  type  of  mental  failure. 
This  type  will  be  considered  under  the  head  of  original 
paranoia. 

The  definition  here  offered  is  as  follows :  Paranoia  is 
a  chronic  form  of  mental  disorder,  on  a  more  or  less  pro- 
nounced degenerative  basis,  characterized  especially  by  sys- 
tematized delusive  conceptions,  without  essential  involve- 
ment of  the  affective  nature,  other  than  may  be  due  to  the 
character  of  the  intellectual  aberrations ,  and  not  ordinarily 
accompanied  by  any  rapid  or  general  failure  of  the 
reasoning  faculties.  The  presence  or  absence  of  hal- 
lucinations is  not  essential  in  this  definition,  and  we 
do  not  recognize  a  special  type  or  species  in  which 
these  are  frequent  and  characteristic.  Hallucinations 
are  common;  in  fact,  they  exist  in  the  majority  of  cases, 


344  DEGENERATIVE    INSANITIES. 

but  are  not  essential,  and  are  therefore  not  included  as 
a  characteristic  feature  in  the  definition.  It  has  the 
advantage  of  being  comprehensive  enough  to  cover 
the  rather  wide  range  of  variations  of  this  type,  which 
clinically  show  an  infinite  number  of  combinations  of 
symptoms,  all,  however,  having  to  a  certain  extent  a 
terminal  tendency  to  general  mental  failure,  but  this 
may  not  appear  for  many  years  after  the  full  develop- 
ment of  the  disease.  In  some  cases,  indeed,  it  never 
appears  to  any  extent ;  the  patient  is  as  clear  mentally 
in  many  respects  as  he  ever  was,  and  his  reasoning 
powers  in  fields  unaffected  by  his  delusions  unimpaired. 
Mental  failure  as  a  terminal  condition,  while  perhaps 
the  rule,  is  not  an  essential  feature  of  the  disorder. 

The  causes  of  paranoia  are  seldom  evident,  though 
its  onset  may  be  attributed  to  any  of  the  moral  or 
physical  causes  that  give  rise  to  mental  disorder. 
These  are,  however,  only  the  apparent  exciting  causes ; 
the  real  beginning  of  the  disorder  frequently  antedates 
them ;  and  in  any  case  they  only  call  out  the  latent  pre- 
disposition. In  nearly  every  case  where  a  history  can 
be  obtained  there  will  be  found  a  morbid  heredity 
either  of  insanity,  intemperance,  or  some  cerebral  or 
nervous  disease  or  degenerative  defect.  While  we  can- 
not say  that  paranoia  may  not  develop  in  a  person 
with  apparently  normal  hereditary  antecedents,  it  may 
be  safely  premised  that  it  never  appears  in  one  who  is 
himself  perfectly  normal,  in  the  sense  of  being  so  free 
from  all  pronounced  degenerative  stigmata,  mental  or 
physical,  as  to  be  considered  an  average  mentally  and 
physically  sound  individual. 

The  beginnings  of  paranoia  are  seldom  well  defined. 
It  is  usual  to  say  that  there  is  a  first  stage  of  hypo- 
chondriacal depression,  a  "  stage  of  subjective  analysis," 
in  which  the  patient  is  disquieted  mentally;  in  which 
he  studies  his  own  morbid  sensations,  real  or  imaginary, 
attaches  importance  to  the  most  trivial  symptoms, 


PARANOIA.  345 

begins  to  analyze  his  own  thoughts  and  feelings,  and 
to  worry  over  them  in  secret,  and  to  apply  to  himself 
morbid  interpretations  of  events  occurring  around  him, 
and  of  the  sayings  of  others.  With  this  tendency  he 
may  have  actual  hallucinations,  though  these  are  less 
frequent  than  in  the  later  stages  of  the  disease.  More 
commonly,  however,  we  find  that  there  has  been  ob- 
served in  him  certain  peculiarities,  dating  back  months 
and  even  years,  which  were  little  remarked  at  the  time, 
but  are  recalled  by  friends  and  acquaintances  after  the 
fully  developed  mental  derangement  has  become  mani- 
fest. The  subject  goes  about  his  ordinary  business, 
and  appears  only  odd  in  manner,  or  a  little  eccentric 
in  certain  ways,  for  a  long  time  before  any  one  really 
recognizes  his  condition,  or  suspects  that  anything 
whatever  is  seriously  amiss .  The  hypochondriacal  symp- 
toms may  be  so  slight  or  obscure  as  to  be  unrecognized 
as  such,  and  the  patient's  self-control  so  well  retained 
that  whatever  he  may  feel  himself  is  only  revealed 
accidentally  in  unguarded  moments,  and  is  then  only 
noticeable  to  close  observers  or  intimate  friends.  It 
is  probable  that  there  is  in  most  cases  a  stage  of  this 
kind  when  the  patient's  ideas  are  centered  on  his  feel- 
ings and  suspicions,  when  he  is  troubling  himself, 
privately  it  may  be,  about  the  significance  of  this  or 
that  event  to  himself,  and  worrying  over  morbid  egotis- 
tic fancies  till  they  affect  his  whole  mental  life,  and 
often,  to  a  noticeable  extent,  his  conduct.  This  stage 
may  be  long  or  short,  or  intermittent,  and  it  is  only  in 
the  minority  of  instances  that  the  conviction  of  his 
insanity  forces  itself  upon  his  friends.  In  these  cases 
the  feeling  of  there  being  something  wrong  with  himself 
or  of  being  wronged  is  so  pronounced  that  it  very 
markedly  affects  the  subject's  conduct,  or  he  may 
betray  himself  by  unguarded  acts  or  recognitions  of 
hallucinations.  These  patients  are  not  usually  com- 
municative as  to  their  feelings,  but  occasionally  one 


346  DEGENERATIVE    INSANITIES. 

will  voluntarily  state  them,  and  seek  relief  or  sympathy 
in  confidences  with  friends.  In  such  cases  the  mental 
tendency  is  more  readily  recognized. 

In  the  great  majority  of  cases  it  is  only  after  the 
victim  has  given  way  to  the  belief  that  there  is  a  reality 
in  the  hitherto  half-formed  delusions,  and  entered  into 
that  state  which  Regis  calls  the  stage  of  "  delusive  ex- 
planation," that  his  insanity  really  becomes  manifest 
to  relatives  and  others  about  him.  He  now  accepts  his 
delusions  as  realities;  feels  himself  an  object  of  perse- 
cution, though  as  yet  he  may  not  definitely  attribute 
it  to  any  individuals.  In  probably  the  majority  of 
cases  there  are  hallucinations,  generally  of  hearing, 
and  these  form  the  basis  of  a  considerable  portion  of 
the  delusions  in  this  form  of  insanity.  The  reticence 
and  self-control  of  the  earlier  stages  having  been  lost, 
the  patient  complains,  often  bitterly,  of  the  annoyances 
and  persecutions  he  undergoes,  but  cannot  sometimes 
definitely  state  what  they  are,  or  what  is  their  source. 
With  a  considerable  proportion  of  the  less  cultured,- the 
mysterious  influences  of  electricity  and  magnetism  are 
credited  with  being  used  against  them;  telephones  or 
wireless  telegraphs  are  sending  messages  in  their  ears ; 
others  claim  to  be  persecuted  by  detectives,  to  be  the 
selected  victims  of  the  Kuklux  Klan,  or  the  Jesuits,  or, 
more  frequently  than  these,  of  the  freemasons.  It  is 
very  exceptional  for  the  hallucinations  or  delusions  to 
take  on  an  agreeable  form,  even  temporarily ;  in  nearly 
every  case  they  are  painful  or  disagreeable.  The 
voices  the  patient  hears  speak  insults;  the  odors  he 
smells  or  the  tastes  he  experiences  are  likewise  disagree- 
able or  disgusting.  All  these  lead  him  to  dwell  more 
and  more  upon  his  delusions,  and  sooner  or  later  he 
locates  his  persecutors,  and  his  delusions  become 
systematized  and  fixed.  It  is  in  this  stage  that  these 
patients  are  most  dangerous,  when  their  delusions  of 
persecution  have  thus  become  established,  and,  their 


PARANOIA.  .  347 

identification  of  their  persecutors  confirmed  in  their 
minds,  these  become  the  objects  of  their  hatred 
and  are  liable  to  become  the  victims  of  their  homi- 
cidal attempts.  The  disease  appears  often  to  so  af- 
fect the  disposition  or  pervert  the  moral  sense  that 
these  patients  are  ready  to  commit  murder,  but  this 
is  not  always  the  case.  When  the  delusions  have 
thus  become  systematized  and  fixed  upon  certain 
persons,  the  paranoiac  is  in  perhaps  the  majority  of 
cases  inclined  to  be  reticent  in  regard  to  them;  he 
knows  his  opinions  are  not  shared  by  others,  and  is 
shy  of  conversing  about  them.  They  are  none  the 
less  dangerous,  however,  and  the  very  reticence  itself 
adds  to  the  peril  of  the  situation,  as  he  gives  his 
victim  no  warning  as  to  his  feelings  in  regard  to  him, 
and  is  therefore  more  able  to  take  him  off  his  guard. 
When  patients  of  this  class  are  sent  to  an  asylum,  it 
is  often  very  difficult  to  ascertain  their  delusions,  and 
sometimes  perilous  to  attempt  it,  as  questioning  only 
arouses  and  adds  to  their  suspicions.  They  are  often 
exceedingly  cunning  in  concealing  their  delusions,  with 
a  fixed  purpose  to  obtain  revenge  or  satisfaction  on 
their  fancied  enemies.  But  while  in  the  great  majority 
the  evil  passions  seem  to  be  predominant  in  this  regard, 
occasionally  we  find  a  case  where  the  moral  sense  is 
still  acute  and  the  self-control  is  exercised  to  prevent 
the  carrying  out  of  the  acts  prompted  by  the  delusions 
and  impulses.  This  implies,  of  course,  an  intellectual 
discrimination  or  judgment  that  the  act  is  wrong, 
notwithstanding  the  fact  they  are  so  strongly  impelled 
to  commit  it,  and  in  these  cases  we  find  very  often  no 
evidence  of  hallucinations,  and  the  individuals  are 
more  likely  to  pass  as  sane,  showing  only  occasionally 
evidence  of  their  aberration  in  their  conduct  or  remarks. 
These  cases  are  also  to  be  considered  dangerous  in  spite 
of  their  self-control.  There  is  always  an  uncertainty 
how  long  it  will  last.     More  frequently  still  in  this  class 


348  DEGENERATIVE    INSANITIES. 

of  cases  the  terror  of  the  law,  or  fear  of  being  com- 
mitted as  insane,  is  an  aid  to  their  conduct  and  keeps 
them  from  acting  on  their  delusions.  We  have  known 
a  man  subject  to  delusions  of  persecution,  a  well- 
marked  paranoiac,  who  for  years  conducted  extensive 
business  transactions,  and  held  public  office,  with 
apparently  no  other  mental  aberration  than  these,  who 
repeatedly  made  personal  assaults  on  those  whom  he 
imagined  were  his  enemies,  and  had  to  be  bound  over 
to  keep  the  peace.  His  case  was  noticeable  in  that 
he  never  seemed  to  think  of  using  deadly  weapons, 
and  in  that  he  was  perfectly  controllable  by  his  respect 
for  the  law,  and  doubtless  more  or  less  also  influenced 
by  his  own  convictions  of  right.  He  was  in  other 
matters  a  good  citizen  and  apparently  a  conscientious 
Christian.  His  violent  acts  appeared  to  be  always 
impromptu,  and  excited  by  the  sudden  meeting  with 
the  persons  involved  in  his  delusions,  which  continued 
till  his  death,  many  years  after  their  first  appearance. 
In  this  case,  as  in  many  others,  the  disease  never  passed 
beyond  this  persecutory  stage,  but  generally  sooner  or 
later,  and  often  simultaneously  with  these  ideas  of 
persecution,  delusions  of  grandeur  or  self-importance 
make  their  appearance.  The  patient  imagines  himself 
some  important  personage;  even  the  Deity  is  often 
personated.  These  ideas  of  importance,  in  some  cases 
at  least,  grow  out  of  the  persecutory  ideas,  the  victim 
of  the  latter  explaining  them  to  himself  on  account  of 
some  special  qualities  and  attributes  belonging  to  him 
personally.  As  a  rule,  however,  they  are  the  index 
of  a  further  advance  toward  general  mental  deteriora- 
tion, which  may  not  have  been  at  all  evident  in  the 
prior  stage,  and  whether  logically  reasoned  out  or  not 
at  first,  they  soon  take  on  an  extravagance  that  indi- 
cates a  decided  loss  of  accurate  reasoning  faculty,  and 
an  increasing  mental  weakness.  One  evidence  of  this 
is  the  tendency  these  patients  often  show,  even  in  the 


PARANOIA.  349 

early  exalted  delusions,  to  manufacture  and  use  odd 
and  meaningless  new  terms.  The  hallucinations  also 
are  generally  more  pronounced  when  they  exist  in  this 
stage,  and  may  involve  other  senses  than  those  first 
affected.  Notwithstanding  these  facts  we  quite  often 
meet  with  cases  where,  notwithstanding  the  appearance 
of  exalted  delusions  and  the  manufacture  of  neologisms 
in  speech,  the  general  mental  deterioration  is  very  far 
from  being  extensive.  In  one  case  under  our  observa- 
tion the  patient,  who  believed  himself  endowed  with  a 
special  mysterious  "Goddy"  power,  about  which  he 
wrote  and  talked,  could  have  passed  as  perfectly  sane 
to  any  casual  observer.  Still  another,  who  had  con- 
stantly the  most  absurd  visual  and  other  hallucinations, 
was  perfectly  sane  on  most  points,  aside  from  his  delu- 
sions, and  a  very  ingenious  mechanic  and  inventor. 

When  this  stage  is  fairly  entered  upon,  the  patient 
is  generally  less  dangerous  than  when  in  the  suspicious 
stage,  but  is  still  not  to  be  considered  as  reliable  or 
safe.  As  mental  weakness  progresses,  the  dangerous 
character  becomes  commonly  less  marked  as  the  patient 
loses  the  persistence  and  the  cunning  that  really  make 
the  persecutory  stage  so  formidable  a  condition. 
Nevertheless,  an  old  chronic  partially  demented  para- 
noiac is  by  no  means  to  be  regarded  as  not  a  poten- 
tial homicide.  The  difference  is  that  here  we  have 
to  do  very  often  with  an  intensely  egotistic  pride 
that  rebels  at  opposition,  and  very  often  also  with 
vicious  impromptu  impulses,  while  in  the  other  case 
we  have  more  frequently  an  intense  hatred  directed 
at  individuals,  based  on  the  delusions  of  injury  or 
insult.  In  the  one  case  there  is  vicious  tendency  on 
casual  provocation;  in  the  other,  persistent  vicious 
motive. 

The  patients,  as  their  disease  progresses  and  the 
megalomania  becomes  more  pronounced,  endeavor  to 
act    out   their   imagined   part,    finally   becoming   less 


350  DEGENERATIVE    INSANITIES. 

dangerous,  as  their  grandiose  delusions  absorb  their 
whole  attention  and  as  they  become  more  demented. 
It  is  a  curious  feature  of  these  cases  that  they  are  for 
the  most  part  unable  to  perceive  the  inconsistency  of 
their  surroundings  and  of  their  own  acts  with  their 
delusive  conceptions.  Thus,  a  patient  who  believes 
himself  the  Deity  will  shovel  manure  in  a  barnyard  or 
do  menial  work  in  the  asylum  ward  with  no  apparent 
conception  that  there  is  anything  out  of  accord  between 
his  claims  and  his  occupation.  These  are  the  patients 
that  decorate  themselves  fantastically  with  tinsel,  old 
buckles,  brass  buttons,  and  trinkets.  In  their  later 
and  more  harmless  stages  they  are  sometimes  met  with 
outside  of  asylums,  and  a  notable  case  of  this  sort  was 
some  years  ago  a  sort  of  public  character  in  one  of  our 
Western  cities.  He  called  himself  the  Emperor  of 
California,  and  was  a  frequent  object  of  interest  to 
strangers  as  he  paraded  in  old  regimentals,  and  was 
generally  a  public  and  privileged  character.  As  a  rule, 
however,  these  patients  are  safest  and  best  cared  for 
in  an  asylum. 

The  typical  case  of  paranoia  or  of  systematized  delu- 
sional insanity  (Magnan,  and  others  of  the  French 
school)  is  divided  into  three  stages,  as  stated  above — 
a  prehminary  hypochondria  or  period  of  subjective 
analysis,  a  stage  of  well-developed  persecutory  delu- 
sions, and  a  final  stage  of  megalomania  and  terminal 
mental  failure.  Not  every  case,  however,  is  typical, 
and  the  first  stage  especially  is  apt  to  be  lacking  in 
the  history  of  the  case.  The  advances  of  its  symptoms 
are  so  insidious  and  obscure,  and  so  marked  by  the 
patient's  own  reticence  and  apparent  sanity,  that  they 
pass  more  often  than  not  without  contemporary 
observation.  The  duration  of  this  stage  is,  therefore, 
hard  to  state;  the  data  we  have  in  regard  to  a  very 
large  proportion  of  cases  are  full  of  eccentricities  or 
peculiarities   hardly  noticed  when  they  occurred,  but 


PARANOIA.  351 

which  are  utilized  in  a  sort  of  retrospective  diagnosis 
of  the  patient's  case  by  his  friends  and  associates 
after  his  mental  aberration  has  become  clearly  mani- 
fest. There  is  reason  to  believe  that  in  many  cases 
this  stage  may  be  of  short  duration,  and  a  compara- 
tively negligible  quantity  in  the  whole  period  of  the 
insanity. 

The  second  stage  of  persecutory  delusional  insanity 
with  hallucinations  and  fixed  delusions  is  the  char- 
acteristic one,  and  it  may  be,  and  often  is,  of  long 
duration,  sometimes  lasting  for  many  years,  the 
patients  never  fairly  passing  into  the  terminal  megalo- 
mania. In  fact,  the  disorder  may  be  arrested  at  any 
stage,  but  most  often  probably  in  the  second.  Many 
people  who  go  through  life  as  eccentric  are  very  pos- 
sibly only  aborted  cases  of  paranoia,  in  whom  the 
progress  was  checked  in  the  early  stage,  and  modified 
into  a  sort  of  crankiness  and  eccentricity,  not  pro- 
nounced enough  for  them  to  be  commonly  reckoned 
insane,  but  sufficient  to  make  them  noticeable  as  odd 
in  behavior  and  generally  peculiar.  They  learn,  more- 
over, to  control  their  conduct  and  conceal  their  feelings 
to  a  very  large  extent,  so  that  their  real  mental  condi- 
tion is  not  betrayed,  except  by  some  habits  of  writing 
or  speech  when  they  are  off  their  guard. 

As  varieties  of  paranoia,  generally  in  its  third  stage, 
we  have  the  erotic,  the  mystic,  the  political,  etc., 
according  as  the  nature  of  the  delusions  partakes  of 
one  or  the  other  of  these  characters.  These  are 
generally  combined  with  the  persecutory  delusions, 
and  also  with  each  other;  thus,  we  may  have  a  religio- 
erotic  persecutory  type,  or  delusions  of  political  im- 
portance may  coexist  with  any  or  all  of  these.  In  one 
case  under  observation  a  telegraph  operator  had  con- 
ceived the  delusion  that  he  had  been  greatly  defrauded 
by  the  Western  Union  Telegraph  Company ;  that  if  he 
had  his  rights  he  would  be  owner  of  larre  blocks  of 


352  DEGENERATIVE    INSANITIES. 

stock,  and  he  was  full  of  threats  and  curses  against  the 
officials  of  the  company,  claiming  to  know  the  most 
disreputable  facts  in  regard  to  them  in  their  public  and 
private  lives.  With  this  there  existed  a  very  marked 
erotic,  or,  rather,  a  satyric  tendency,  which  led  him  to 
constantly  write  the  most  abominable  compositions 
and  address  letters  of  the  same  character  to  women 
whom  he  happened  to  see  or  hear  about.  More  often, 
however,  the  erotic  tendency  shows  itself  in  a  romantic 
or  Quixotic  way,  and  it  is  in  still  other  cases  accom- 
panied with  sexual  hallucinations.  While  these  pa- 
tients are  sometimes,  and  in  some  respects,  less  danger- 
ous than  those  with  purely  persecutory  delusions,  the 
difference  is  largely  in  degree  only,  and  they  are  not 
to  be  trusted.  The  fact  that  other  matters  than  their 
wrongs  and  their  persecutions  engage  their  attention 
to  a  greater  or  less  extent  does  not  invariably,  or  as  a 
rule,  prevent  them  from  dwelling  on  the  latter  and 
planning  revenge. 

Another  well-marked  variety,  that  has  been  made  a 
special  type,  particularly  by  the  Germans,  is  the 
litigious  paranoia,  the  "  Querulantenwahnsinn  "  of  Ger- 
man authors.  This  form  is  usually  first  apparent  in 
its  subjects  after  some  disappointment  in  a  law-suit, 
which  apparently  gives  the  starting-point  for  the  build- 
ing of  delusions  in  the  unstable  mental  organization. 
There  have  been  antecedents,  but  they  have  generally 
passed  unnoticed ;  the  degenerative  stigmata  are  usually 
marked.  The  patients  show  their  insanity  in  constant 
litigation.  They  are  continually  starting  suits  and 
demanding  justice.  Their  egoism  is  excessive,  and 
their  moral  sense  so  defective  that  they  can  never 
recognize  the  real  relations  of  things,  and  they  build  up 
extensive  delusions  as  to  the  rights  they  are  deprived 
of  and  the  wrongs  they  have  suffered.  The  disorder 
may  be  considered  as  a  special  development  of  per- 
secutory insanity,   and  is  often  associated  with  the 


PARANOIA.  353 

ordinary  delusions  of  persecution  to  some  extent.  It 
may  also  present  the  erotic  phase  of  paranoia,  as  in  a 
well-marked  case  that  was  for  years  under  the  writer's 
observation.  The  patient  was  a  Scotchman,  of  re- 
spectable family,  and  general  business  education,  who 
came  to  this  country  many  years  ago  with  a  consider- 
able sum  of  money,  which  he  invested  in  lands  and 
mining  properties.  His  full  family  history  is  unknown, 
but  there  was  most  probably  a  strong  hereditary  taint. 
For  a  number  of  years  he  carried  on  extensive  opera- 
tions with  more  or  less  success,  but  finally  became  in- 
volved, and  his  litigious  insanity  developed.  He  soon 
had  a  whole  community  involved  in  law-suits,  started 
on  trivial  pretexts,  and,  of  course,  futile,  but  annoying, 
expensive,  and,  if  not  attended  to,  liable  to  give  trouble 
to  property-owners  whose  titles  were  attacked.  The 
nuisance  created  became  so  great  that  he  was  in  peril 
of  his  life  from  some  of  the  more  desperate  of  those 
whom  he  attacked  in  the  courts,  and  finally  he  was 
shot,  the  ball,  it  is  said,  penetrating  the  skull  and 
lodging  in  the  brain.  It  had,  however,  little  effect  on 
him,  except  to  make  him  worse,  and  finally  his  insanity 
was  recognized,  and  he  was  committed  to  an  asylum. 
While  in  the  asylum  there  was  no  change  in  the  condi- 
tion, though  he  remained  there  some  years.  He  was 
constantly  boisterous  and  threatening,  demanding  his 
liberty,  and  seeking  every  means  to  escape.  He 
claimed  to  have  large  sums  due  him  which  he  was  sure 
to  get  from  law-suits  pending.  He  was  exceedingly 
abusive  to  the  physicians,  profane,  and  threatening 
violence,  legal  proceedings,  etc.,  unless  he  was  released. 
He  wrote  many  letters,  some  to  lawyers  and  others  to 
women  whose  names  he  obtained,  the  latter  generally 
proposing  marriage,  or  representing  himself  as  a 
capitalist  desiring  to  marry,  and  wishing,  therefore,  to 
correspond  with  that  in  view.  Some  of  these  letters 
were  very  improper  in  sentiment  and  language ;  others, 


354  DEGENERATIVE    INSANITIES. 

which  he  addressed  to  the  superintendent  or  to  the 
physicians,  were  equally  objectionable  in  other  ways. 
A  curious  feature  of  some  of  these  was  the  occasional 
use  of  the  ordinary  conventional  formulas  of  politeness, 
entirely  out  of  accord  with  the  general  contents  of  the 
missive;  thus,  for  example,  he  would  begin  an  out- 
rageously abusive  letter  with  "Dear  Sir,"  and  end  it 
with  "Your  warm  friend,"  or  something  equivalent. 
At  times  he  was  dangerous,  but  generally  only  when 
he  thought  he  had  the  advantage.  He  once  knocked 
an  attendant  senseless  with  a  piece  of  iron  tubing  he 
picked  up  when  on  a  walk  with  the  other  patients. 
His  memory  was  perfect;  his  reasoning  powers,  aside 
from  his  delusions,  seemed  but  little  impaired,  though 
there  were  some  evidences  of  it  in  his  writing,  such  as 
that  mentioned  above,  and  he  was  decidedly  insane  in 
manner  and  acts.  There  was  no  evidence  of  any  hallu- 
cinations. He  made  his  escape  several  times,  but  was 
generally  arrested  sooner  or  later  for  some  misdemeanor 
or  minor  offense,  and  his  insanity  recognized.  He  was 
once  or  twice  taken  out  of  jails  or  bridewells  and 
returned  to  the  asylum.  He  was  able  to  excite  sym- 
pathy as  an  abused  individual,  and  on  one  occasion  he 
obtained  a  certificate  of  sanity  from  a  prominent 
physician  without  examination,  the  giver  afterward 
saying  that  he  gave  it  "  to  bother  the  doctors. ' '  Finally 
he  managed  to  get  his  freedom  on  a  writ  of  habeas 
corpus,  the  judge  calling  a  jury  to  share  his  responsi- 
bility, and  followed  a  sort  of  vagabond  life  for  a  few 
months,  showing  rather  more  decided  evidences  of 
mental  impairment,  and  was  at  last  killed  by  a  train 
while  walking  on  a  railroad  track. 

Cases  of  this  kind  are  rather  sharply  distinguished 
from  the  typical  forms  of  paranoia — that  is,  of  sys- 
tematized delusional  insanity — by  the  absence  of  hal- 
lucinations, by  the  combination  of  erotic  and  persecu- 
tory delusions,  and  in  most  cases  by  the  more  marked 


PARANOIA.  355 

degenerative  stigmata,  both  physical  and  mental. 
These  patients  have  usually  been  peculiar ;  they  have 
shown  lack  of  mental  equilibrium  in  some  way  or 
other  all  their  lives,  and  their  insanity  is  generally 
what  we  might  call  the  mental  physiologic  consequence 
of  their  degenerative  development.  Their  insanity  is, 
moreover,  not  progressive,  as  in  the  typical  paranoia, 
and  is  not  in  such  sharp  contrast  to  their  previous  life 
and  behavior.  The  patient  above  described  falls  into 
the  class  of  persecutory  delusional  insanity  of  the 
degenerates  of  Magnan,  which  he  definitely  separates 
from  his  chronic  delusional  insanity  of  systematic  evo- 
lution, which  comprises  what  we  have  designated  as 
typical  paranoia.  Nevertheless,  it  seems  to  us  that  the 
distinction  is  one  of  degree  rather  than  of  kind,  and  that 
the  two  types  graduate  into  each  other.  In  this  more 
degenerative  form  of  insanity  there  is  not  the  sys- 
tematic progression,  it  is  true,  and  the  lack  or  rarity 
of  sensory  symptoms  is  usually  a  rather  striking  dif- 
ference, but  cases  occur  where  they  are  present,  and, 
as  a  rule,  so  far  as  we  have  been  able  to  observe,  there 
has  been  a  certain  progressive  tendency  toward  further 
mental  deterioration,  slow,  it  is  true,  but  perceptible. 
This  special  persecutory  litigious  type  is  less  pro- 
nouncedly a  degenerative  one  than  that  next  to  be 
described,  but  forms,  as  it  were,  a  transition  between 
it  and  the  typical  paranoia. 

The  variety  of  paranoia  now  to  be  described  is  so 
different  in  many  respects  from  the  typical  progressive 
form  that  there  is  some  question  whether  it  should  be 
included  under  the  same  species.  As  already  said, 
Magnan  distinguished  the  insanity  of  the  degenerates 
as  a  well-marked  and  distinct  type,  and  some,  at  least, 
of  the  Italian  school  also  make  a  sharp  distinction 
between  the  degenerative  paranoias  and  the  chronic 
systematized  type.  Under  the  former  they  include  a 
number  of  conditions  under  various  names — mattoid, 


356  DEGENERATIVE    INSANITIES. 

degenerative,  episodic  insanities,  original  paranoia,  etc. 
Under  this  latter  head  falls  the  special  type  here  to  be 
described,  which  is  the  extreme  degenerative  one  here 
included  under  paranoia.  The  term  original  paranoia 
was  proposed  by  Sander  to  cover  these  and  possibly 
some  other  conditions,  and  is  used  by  some  authors  to 
include  also  the  form  just  described,  as  well  as  mystic, 
erotic,  and  religious  variations.  These,  we  hold,  how- 
ever, develop  especially  in  the  third  stage  of  the  typical 
form,  though  less  frequently,  and  the  litigious  variety 
may  arise  in  the  second  stage,  and  often  is  in  many 
respects  a  less  essentially  degenerate  type  than  the 
variety  here  to  be  considered.  All,  as  already  stated, 
fall  under  the  head  of  insanity  of  the  degenerates,  as 
distinguished  by  Magnan  and  his  school. 

Original  paranoia  as  here  understood  is  a  congenital 
degenerative  defect,  marked  by  very  prominent  physi- 
cal stigmata,  and  mental  defects  appearing  often  from 
early  youth,  and  becoming  more  pronounced  at  the 
critical  stages  of  development,  with  very  notable 
mental  deficiencies  in  certain  directions  that  ally  these 
cases  closely  to  the  imbeciles  and  semi-imbeciles.  Un- 
like the  typical  paranoiac,  the  original  paranoiac  begins 
to  show  his  defects  early,  long  before  there  is  any 
decidedly  insane  manifestation.  Instead  of  a  more  or 
less  masked  hypochondriac  stage,  lasting  seldom  over 
a  year  or  two,  and  beginning  in  an  apparently  normal 
individual,  there  is  commonly  in  typical  instances  of 
this  type  a  peculiarity  dating  back  to  childhood,  and 
especially  becoming  manifest  at  puberty  or  shortly 
after.  There  is  also  in  these  cases,  as  in  the  others,  a 
very  decided  neurotic  or  neuropathic  heredity,  and 
often  a  direct  heredity  of  insanity  or  eccentricity  in 
one  form  or  another.  These  patients  in  childhood  are 
often  reckoned  as  precocious;  they  are  apt  to  be  quiet, 
sedate,  and  retiring  in  disposition,  and  to  show  little 
of  the  natural  joyousness  of  childhood.     If  they  do  go 


PARANOIA.  357 

with  other  children  in  their  plays,  their  peculiarities 
are  soon  noted,  and  gain  them  some  nickname  that 
indicates  them.  Sexual  precocity  is  not  uncommon, 
and  masturbation  is  frequent.  If  they  appear  to  show 
mental  capacity,  it  is  likely  to  be  in  certain  directions, 
and  is  marked  by  self -consciousness  and  exaggeration. 
They  are  often  moody  and  inclined  to  revery  and 
fancies,  and  all  these  peculiarities  are  commonly  intensi- 
fied at  or  about  puberty,  and  often  their  mental  weak- 
ness shows  itself  in  their  incapacity  for  ordinary  busi- 
ness and  their  shifting  and  uncertain  dispositions. 
Their  insanity  is  recognized  generally  only  after  some 
outre  or  criminal  act,  or  when  their  peculiar  delusive 
ideas  begin  to  affect  their  behavior.  They  differ  from 
the  paranoiacs  already  described  in  the  genesis  of  their 
insanity  and  delusions;  in  the  former  the  mental  dis- 
order originates  from  an  apparently  normal  condition ; 
there  is,  it  is  true,  a  marked  heredity  and  a  degenera- 
tive basis,  but  these  are  not  conspicuous  till,  after  some 
cause,  apparent  or  otherwise,  the  unstable  brain  gives 
way,  and  the  insanity  manifests  itself.  There  is  first 
an  emotional  depression,  a  period  of  morbid  intro- 
spection followed  by  hallucinations  in  most  cases,  and 
the  building  up  of  delusions  upon  them.  There  is 
possible,  as  Hirsch  has  suggested,  an  eccentric  pro- 
jection of  ideas  corresponding  to  that  from  the  sensory 
centers  in  the  hallucinations,  thus  giving  rise  to  the 
delusions.  The  condition  is  a  pathologic  one,  though 
imposed  upon  a  predisposed  and  more  or  less  defective 
organization.  In  original  paranoia,  on  the  other  hand, 
the  mental  disorder  is  in  the  natural  order  of  the 
patient's  development,  the  inevitable  result  of  his 
defective  organization.  His  is  a  teratologic  rather 
than  a  pathologic  insanity.  There  is  no  essential 
morbid  preliminary  depression,  and  there  are  rarely 
any  hallucinations,  but  there  are  day-dreams  and  fan- 
cies that  he  builds  up  into  delusions,  not  irresistibly 


358  DEGENERATIVE    INSANITIES. 

forced  upon  him  by  hallucinations,  but  courted  and 
encouraged  by  himself.  In  some  cases  the  individual 
is  clearly  aware  of  their  unreality,  but  in  most  they 
come  sooner  or  later  to  be  accepted  as  true,  and  to 
control  acts.  These  patients  form  the  great  majority 
of  the  mystic,  erotic,  and  political  paranoiacs,  and  a 
large  proportion  of  the  querulant  type,  which  may  be 
considered  as  a  variety,  as  already  remarked,  midway 
between  this  and  the  typical  pathologic  form. 

The  much-discussed  mental  status  of  the  assassin 
Guiteau  comes  very  apropos  in  considering  this  part  of 
our  subject.  Beyond  the  general  one  of  his  own  im- 
portance, which  dominated  his  whole  life,  it  appears 
questionable  whether  Guiteau  ever  had  a  fixed  delu- 
sion, or  any  honest  delusion  at  all.  His  defective 
mental  organization  was  such  that  he  was  incapable 
of  appreciating  his  own  behavior  and  its  consequences ; 
he  was  thoroughly  insane  in  his  judgment,  but  it  seems 
very  doubtful  whether  his  vicious  day-dreams  were 
any  more  realities  to  him  than  to  those  who  heard 
them  told,  except  upon  the  principle  that  a  man  can 
tell  himself  a  lie  till  he  comes  more  or  less  to  believe 
in  it  himself.  His  delusions  do  not  appear  to  have  been 
permanent  systematized  ones  due  to  special  organic 
defects;  they  were  rather  due,  so  far  as  they  existed, 
to  his  mental  and  moral  degeneration  and  weakness. 

This  view  of  the  Guiteau  mental  condition  is  con- 
firmed by  the  observation  of  two  or  three  patients 
whose  cases  appeared  to  be  very  similar  to  his.*  "The 
most  striking  of  these  is  a  female,  thirty-three  years 
of  age,  who  is  said  to  have  a  heredity  of  insanity  from 
several  generations  of  ancestors  on  the  paternal  side. 
Her  father,  while  not  insane,  is  notably  eccentric ;  her 
mother  appears  to  have  been  weak  and  hysteric ;  one 
brother  has  been  insane  and  an  inmate  of  the  same 

*  H.  M.  Bannister,  "Monomania,"  "Am.  Jour.  Neurol  and 
Psych.,"  1884. 


PARANOIA.  359 

hospital  as  herself.  Physically  she  is  undersized  and 
noticeably  unsymmetric,  one  leg  being  considerably 
smaller  than  the  other  from  paralysis  in  infancy.  She 
is  said  to  have  had  convulsions,  but  these  were  probably 
only  hysteric  ailments;  her  health  is  pretty  good,  her 
menses  are  fairly  regular,  there  is  no  very  marked 
cranial  asymmetry,  though  her  head  is  slightly  depressed 
in  the  median  line  from  the  vertex  to  the  occipital  pro- 
tuberance, and  rather  more  protuberant  in  the  right 
parietal  region  than  in  the  left.  There  is  a  certain  want 
of  symmetry  in  her  face,  especially  noticeable  in  expres- 
sion, but  it  is  not  easily  determined  by  measurements. 
"  She  has  always  been  wilful  and  unmanageable  and 
perverse  in  her  ways  since  childhood,  though  her  friends 
were  not  willing  to  consider  her  deranged.  She  has  had 
a  fair  English  education,  has  done  a  great  deal  of 
desultory  reading,  and  has  a  notable  facility  of  expres- 
sion of  a  certain  sort  both  in  speech  and  in  writing,  and 
a  good  memory,  so  that  she  is  able  to  reproduce  whole 
poems  in  her  writing  (sometimes  altered  to  suit  her 
ideas)  without  crediting  the  authors.  She  has  been, 
according  to  her  own  statements,  successively  a  ritual- 
ist, a  Catholic,  a  Presbyterian,  a  Swedenborgian,  and  a 
Congregationalist,  and  at  the  time  of  observation  she 
claims  to  be  a  high-church  Episcopalian.  Indeed, 
her  religious  vagaries  were  the  matters  that  most 
distressed  her  friends  for  many  years  prior  to  their 
considering  her  actually  insane.  A  year  or  two  before 
her  commitment  as  insane  she  became  infatuated  with 
a  popular  preacher,  and  persecuted  him  so  with  love- 
letters  and  by  attempting  to  attract  his  attention  and 
obtain  interviews  with  him  that  the  steps  were  finally 
taken  that  led  to  her  being  shut  up  in  an  asylum. 
Her  committal  papers  state  that  her  insanity  was  of 
twelve  years'  duration,  which  covers  the  period  of  her 
public  eccentricities  and  her  religious  wanderings  and 
dates  its  beginning  at  her  nineteenth  year. 


360  DEGENERATIVE    INSANITIES. 

"After  a  few  months'  stay  in  the  hospital  to  which 
she  was  first  sent,  she  was  allowed  to  visit  home,  but 
soon  had  to  be  returned.  During  this  furlough  she 
absented  herself  from  home,  and  was  only  found  after 
several  days'  search  by  her  friends,  in  the  church  of  her 
admired  preacher. 

"  Since  her  return  to  the  hospital  there  has  been 
very  little  change  in  her  mental  condition,  though  what 
there  is  has  been  for  the  worse.  She  is  capable  of 
talking  sensibly  and  appearing  perfectly  rational,  and 
has  often  surprised  visitors  who  have  conversed  with 
her  by  her  apparent  sanity,  though  there  is  generally 
something  fantastic  in  her  dress  or  manner  which,  seen 
in  such  a  place,  makes  her  appear  conspicuously  insane 
to  the  casual  observer.  She  delights  in  getting  up 
oddities  of  costume,  especially  when  she  has  a  chance 
to  display  them  in  public,  as  at  chapel  services,  enter- 
tainments, etc.,  and  when  not  allowed  to  rig  herself 
out  too  conspicuously,  will  have  at  least  some  fantastic 
embroidery  or  other  striking  peculiarity  in  her  dress. 
In  fact,  her  behavior  generally  is  marked  by  a  desire 
to  be  noticeable  in  some  striking  way,  and  she  is  never 
better  satisfied  than  when  she  feels  that  she  is  producing 
a  sensation.  There  is  a  strong  erotic  tendency;  she 
is  very  much  inclined  to  write  ardent  letters  to  some 
male  individual  with  whom  she  may  perhaps  have  no 
personal  acquaintance  whatever,  and,  judging  from 
her  talk  at  times,  her  feelings  in  this  direction  are  not 
always  purely  romantic.  She  is  a  very  troublesome 
patient  in  some  respects,  and  seems  at  times  to  en- 
deavor to  be  as  irritating  as  possible  to  attendants  and 
those  about  her.  While  seldom  or  never  violent,  she 
can  make  more  ingeniously  insulting  remarks  to  and 
about  her  attendants  than  any  patient  I  have  known, 
and  utterly  disregards  all  the  conventional  proprieties 
of  language  in  so  doing.  On  this  account,  she  seldom 
is  kept  long  in  any  one  ward,  as  an  occasional  change 


PARANOIA.  361 

seems  to  improve  temporarily,  to  some  extent,  her  too 
trying  disposition. 

"The  point,  however,  in  her  case  which  is  of  most 
interest  here  is  in  the  character  of  her  apparent  delu- 
sions. I  say  apparent,  for  their  unreality  to  her  is 
manifest  at  times  to  any  observer.  There  is  nothing 
fixed  or  permanent  about  them;  at  one  time  she  is  to 
be  the  mother  of  a  coming  Messiah ;  at  another,  she  is 
heiress  to  the  British  crown ;  and,  again,  she  claims  to 
rule  the  American  people  as  queen;  and  next  she  will 
laugh  at  her  own  notions,  and  admit  that  they  are 
absurd.  She  will  write  a  most  loving  letter  to  some 
man  who  is  at  the  time  the  object  of  her  affections,  and 
then  write  one  in  reply  to  herself,  addressing  herself  as 
'  My  loving  wife,'  etc.  Her  inability  to  live  altogether 
in  the  unreal  world  she  pictures  for  herself  in  her  day- 
dreams, and  the  conflict  between  them  and  the  realities 
she  appreciates  about  her,  will  probably  account  for 
much  of  her  discontent,  and  help  to  explain  some  of  her 
worst  behavior.  These  day-dreams,  though  not  reali- 
ties to  her,  yet  dominate  her  whole  thought  and  in- 
trude themselves  into  everything  she  writes,  though 
the  mental  friction  of  conversation  appears  to  enable 
her  to  often  talk  at  length  very  sensibly  on  almost  any 
subject  with  which  she  is  at  all  conversant.  She  is 
conscious  of  her  own  mental  weakness,  and  when  asked 
recently  what  she  soberly  thought  of  her  own  case, 
she  replied :  '  I  am  not  exactly  insane ;  I  am  only  a  sort 
of  an  imbecile,'  and  then,  apparently  wishing  to  modify 
the  admission  she  had  made,  she  added :  '  But  you 
know  the  foolish  things  of  this  world  are  to  confound 
the  wise.'  It  is  not  often  that  she  will  acknowledge 
as  much  as  the  above,  though  she  frequently  admits 
that  her  pretensions  are  ridiculous,  and  that  her 
behavior  is  unreasonable. 

"  If  this  patient  had  been  of  the  opposite  sex,  and 
had  the  training  and  experiences  of  a  man,  it  is  prob- 


362  DEGENERATIVE    INSANITIES. 

able  that  the  development  of  her  insanity  would  have 
been  somewhat  different,  and  I  can  readily  imagine 
that  under  such  conditions  she  might  have  been 
another  Guiteau.  They  are  alike  in  their  bad  heredity, 
their  overbearing  egotism,  their  peculiar  religious  and 
erotic  tendencies,  their  ability  to  deceive  as  to  their 
real  mental  status,  and,  I  believe,  they  both  had  the 
same  type  of  pseudo-delusions." 

The  case  of  Prendergast,  the  assassin  of  the  Hon. 
Carter  H.  Harrison,  was  also  one  of  this  form  of  para- 
noia. He  was  born  in  Ireland,  and  came  to  this 
country  as  a  babe;  his  father  was  an  inebriate,  and 
several  of  his  paternal  ancestors  were  insane.  His 
mother  was  a  strong  woman,  with  no  bad  heredity  that 
was  ascertained.  In  early  childhood  he  sustained  a 
head  injury  by  falling  that  made  him  unconscious  for 
several  hours.  This  was  followed  by  more  or  less  head- 
ache. As  a  boy  he  showed  peculiarities,  was  very 
irritable,  and  did  not  care  for  the  companionship  of 
other  boys.  He  went  to  school  for  a  few  years,  and 
made  very  good  progress.  He  became  a  newsboy  and 
did  quite  as  well  as  such  boys  generally  do,  but  was 
rarely  on  good  terms  with  the  other  boys.  As  he  grew 
older,  he  became  a  deliverer  of  daily  papers  on  a  some- 
what secluded  route,  and  did  this  work  to  the  satis- 
faction of  all.  About  the  age  of  fifteen  he  began  to 
develop  delusions  of  persecution;  thought  the  other 
newsboys  were  combined  against  him,  that  they  were 
making  misrepresentations  about  him,  and  that  his 
mother  and  brother  were  also  against  him  and  con- 
stantly trying  to  do  him  harm.  A  little  later  than  this 
there  was  much  agitation  in  the  Chicago  papers  about 
the  dangers  of  railroad  grade-crossings  and  the  neces- 
sity of  stopping  the  loss  of  life  by  track  elevation. 
Then  he  became  possessed  of  the  delusion  that  he  was 
God's  appointed  agent  to  bring  about  this  important 
work.     To  do  it,  he  conceived  the  idea  that  he  must 


PARANOIA.  363 

be  made  the  Corporation  Counsel  of  Chicago.  This  is 
an  appointive  office  by  the  Mayor  of  Chicago,  and 
demands  legal  talent  of  the  highest  order.  As  soon  as 
Mayor  Harrison  was  elected,  he  applied  to  him.  After 
Hon.  A.  Krauss  had  been  appointed,  he  called  upon 
him  and  several  times  demanded  the  office  as  his,  by 
right,  as  the  Almighty's  agent.  At  the  time  of  the 
assassination  he  went  in  the  early  evening  to  the 
Mayor's  residence  and  made  the  same  demand.  Being 
refused,  he  shot  him,  and  immediately  thereafter  went 
to  the  police  station  and  gave  himself  up.  At  this  sta- 
tion he  was  regarded  as  insane,  and  they  at  first  deter- 
mined to  send  him  to  the  Detention  Hospital  for  the 
Insane.  The  neighbors  across  the  street  heard  the  shot 
fired,  went  over  immediately,  and  no  one  had  the 
slightest  idea  who  did  it.  Mr.  Harrison  himself  had 
admitted  Prendergast ;  no  one  saw  him  leave,  and  the 
Mayor  died  without  giving  any  information  about  it. 
At  the  police  station  Prendergast  insisted  that  he  did 
it ;  that  he  was  the  divinely  appointed  agent  to  elevate 
the  railroad  tracks,  and  in  order  to  do  it  properly  he 
must  be  Corporation  Counsel.  The  Mayor  refused  to 
do  it,  and  the  Lord  had  commanded  him  to  remove 
him.  He  seemed  sorry  enough,  but  said  he  must  do 
as  the  Almighty  demanded.  In  due  course  of  time  he 
was  tried  by  jury.  He  was  the  son  of  a  washerwoman, 
and  a  newsboy,  and  had  killed  the  Mayor  of  a  great 
city  at  the  time  of  the  closing  exercises  of  the  great 
Columbian  Exposition.  The  excitement  was  intense, 
and  the  people  almost  with  one  accord  demanded  his 
blood.  The  case  showed  the  utter  unreliability  of  the 
American  method  of  securing  expert  testimony;  the 
Commonwealth  found  many  physicians  to  testify  to  the 
sanity  of  the  poverty-stricken  and  deluded  boy.  In 
various  interviews  he  always  admitted  the  killing,  and 
always  justified  it  by  his  delusions ;  he  seemed  to  be  very 
sorry  that  it  had  to  be  done.     Upon  other  topics  he 


364  DEGENERATIVE    INSANITIES. 

talked  as  well  as  could  be  expected  with  his  limited  edu- 
cation, showing  a  good  memory  and  emotional  control. 
He  had  numerous  stigmata  of  degeneracy ;  the  shape  of 
the  head  was  quite  abnormal,  very  deficient  in  frontal 
development,  and  quite  excessive  in  occipital.  There 
was  marked  arrest  of  development  of  the  superior 
maxillae,  prognathism,  great  prominence  of  the  malar 
bones,  asymmetry  between  the  two  sides  of  the  face, 
the  orbital  cavities  were  large  and  widely  separated, 
the  teeth  were  deformed,  and  the  palatine  arch  was 
saddle-shaped.  The  upper  extremities  were  very  long, 
the  finger-tips  extending  an  inch  below  the  knee.  The 
ears  were  too  large,  not  on  the  same  level,  too  far  front, 
conchas  greatly  enlarged,  lobule  deformed,  and  two 
Darwin  tubercles  on  each  helix.  The  penis  was  un- 
usually large  and  one  testicle  had  not  descended. 
After  two  jury  trials  he  was  condemned,  and  in  due 
time  hanged.     No  postmortem  was  permitted. 

The  pathologic  anatomy  of  paranoia  is  unknown, 
aside  from  the  degenerative  stigmata  already  men- 
tioned. Among  these  the  most  important  are  cranial 
and  convolutional  anomalies,  asymmetries,  etc.,  which 
are  most  pronounced  in  the  type  last  described — the 
original  paranoiacs.  In  these  they  are  rarely  lacking, 
or,  rather,  are  seldom  not  markedly  prominent.  In 
long-continued  cases  of  the  typical  form  when  the 
disease  has  progressed  to  the  final  stage  of  dementia, 
we  find  on  autopsy  the  typical  lesions  of  that  condition, 
cerebral  atrophy,  and  often  more  or  less  thickening 
and  opacity  of  the  membranes.  The  same  is  probably 
to  be  found  in  the  original  paranoiac  after  long  con- 
tinuance of  the  condition.  In  the  assassin  Guiteau 
some  evidences  of  a  more  acute  cerebral  pathologic 
condition  were  found,  but  his  case  was  exceptional  in 
other  respects,  and  possibly  also  in  this. 

The  diagnosis  of  paranoia  is  ordinarily  easy  after 
the  disorder  is  fairly  under  way.     In  the  early  stages 


PARANOIA.  365 

of  the  typical  form  there  is  a  chance  that  it  may  be 
mistaken  for  melancholia,  but  more  often  a  danger 
that  it  will  not  be  recognized  at  all.  After  hallucina- 
tions have  appeared  and  persecutory  delusions  exist, 
the  patient  may  still  be  able  to  conceal  his  insanity  to 
a  great  extent,  and  in  this  lies  the  greatest  peril  of  the 
disease.  The  walking  cases  of  paranoia,  unrecognized 
by  the  laity,  and  often  protected  in  their  freedom  by 
the  courts,  are  one  of  the  greatest  public  dangers  and 
the  cause  of  a  very  large  proportion  of  the  tragedies 
that  shock  the  public  from  time  to  time. 

There  are  many  insane  conditions  where  delusions 
predominate  that  are  not  paranoia,  and  some  of  these 
have  been  already  described.  The  secondary  delu- 
sional insanities  may  be  confused  with  the  later  stages 
of  this  disorder,  but  the  difference  is  practically  un- 
important, as  this  is  itself  a  secondary  condition.  The 
megalomania  of  the  third  stage  of  paranoia  is,  however, 
often  characteristically  blended  with  some  traces  of 
the  earlier  delusions,  so  that  it  can  be  distinguished 
from  that  following  other  forms  of  mental  disorder. 
In  the  early  stages  there  may  be  a  confusion  with 
melancholia,  especially  the  hypochondriacal  type,  but 
the  melancholiac  is  self -accusatory,  which  is  not  the 
case  with  the  paranoiac.  The  paranoiac  type  of 
alcoholic  insanity  has  much  resemblance  to  certain 
cases  of  paranoia  in  its  delusions  and  their  dangerous 
character,  and  often  it  is  well  to  reserve  a  positive 
diagnosis  between  these  two  conditions.  As  Regis 
says,  also,  there  are  cases  where  the  incipient  paranoiac 
takes  to  drink  under  the  influence  of  his  feelings,  and 
this  may  confuse  matters.  Hallucinations  of  hearing 
are,  however,  unusual  in  alcoholic  insanity,  while  they 
are  almost  characteristic  of  paranoia,  and  their  ex- 
istence or  development  may  assist  or  be  suggestive. 

The  delusional  early  stages  of  paresis  may  possibly 
be  confused  with  this  form,  though  generally  a  little 


366  DEGENERATIVE    INSANITIES. 

close  attention  will  settle  the  question  definitely.  The 
presence  or  absence  of  the  physical  signs  and  the  fleeting 
and  changeable  nature  of  the  delusions  of  paresis  are  also 
generally  characteristic.  In  some  pre-  or  post-epileptic 
conditions  also  there  may  be  a  predominance  of  delusions 
that  might  suggest  paranoia,  especially  if  the  convulsive 
phenomena  are  slight  or  masked;  but  these  are  tem- 
porary conditions.  The  same  may  be  said  of  certain 
episodic  conditions  in  degenerates  which  closely  re- 
semble paranoia,  and  the  existence  of  which  has  pos- 
sibly led  to  the  conception  of  an  acute  paranoia. 
These  occur  in  decidedly  predisposed  individuals,  but 
who  are  ordinarily  not  fully  over  the  border  of  insanity, 
and  are  generally  of  short  duration.  Sometimes  there 
is  a  strong  suggestion  of  drug  intoxication  in  these 
cases,  and  possibly  this  may  be  accounted  for  by  some 
of  the  secret  drug  habits. 

The  prognosis  of  the  disorder  is  generally  bad,  the 
tendency  is  in  all  forms  progressive,  and  it  may  be  said 
to  be  in  a  general  way  incurable.  Once  in  a  while, 
hoAvever,  the  disordered  intellection  seems  to  be  stayed 
at  certain  stages,  and  there  may  be  even  an  apparent 
improvement.  We  have  seen  a  case  that  had  passed 
into  the  megalomaniac  phase  apparently  become  aware 
of  the  absurdity  of  some  of  his  ideas  and  undergo  a 
sort  of  apparent  "recovery  with  defect."  His  death 
occurred  so  shortly  after  his  removal  from  the  asylum 
that  it  could  not  well  be  said  that  the  change  was 
permanent,  and  such  happenings  are  exceedingly  rare. 
The  mental  disease  does  not,  except  as  secondary 
dementia,  directly  tend  to  shorten  life ;  but  in  a  general 
way,  without  perhaps  any  very  definite  reasons  for  it, 
one  would  have  to  consider  a  paranoiac  a  bad  life-risk. 
The  tendency  to  suicide  may  arise,  and  in  other  ways 
there  is  so  much  uncertainty  as  to  their  behavior  or 
personal  care  of  themselves  that  it  is  impossible  to 
insure  against  dangers  either  from  accident  or  disease. 


PARANOIA.  367 

The  treatment  of  these  cases  is  largely  moral;  as 
might  be  supposed,  there  are  few  or  no  tangible  physical 
symptoms  to  treat.  One  is  limited  to  the  watching  for 
complications  and  meeting  them  as  they  arise.  Some- 
times, under  the  influence  of  delusions  of  poison,  etc., 
the  patients  may  refuse  food,  and  this  may  possibly  go 
so  far  as  to  endanger  their  health.  Forced  feeding  for 
any  considerable  period,  however,  is  rarely  necessary, 
and  should  be  avoided  altogether  if  possible,  as  it  will 
be  likely  to  aggravate  the  delusions  and  excite  danger- 
ous antagonisms. 

Confinement  in  an  asylum  or  hospital  for  the  insane 
is  a  very  essential  part  of  the  treatment,  both  for  the 
patient  and  the  public,  and  for  the  influence  of  the 
regulated  living  and  discipline  of  an  asylum,  since  more 
than  any  other  insane  they  can  appreciate  the  reasons 
and  often  the  reasonableness  of  their  seclusion.  Upon 
many  of  them  it  has  a  very  happy  effect ;  in  other  cases 
it  may  be  resented,  and  they  become  the  more  danger- 
ous patients.  In  some  of  the  less  aggressive  cases 
during  the  period  of  the  prevalence  of  the  persecutory 
delusions,  it  is  felt  doubtless  as  a  refuge  from  their 
persecutors.  If  suitable  employment  is  given  under 
judicious  control,  the  delusions  often  become  less 
prominent,  at  least  objectively,  and  the  patients  seem 
to  be  actually  improving  mentally.  There  is  still 
another  class  of  these  patients  in  whom  the  delusions 
are  not  so  imperative  in  their  nature,  and  in  whom 
there  is  still  such  a  strong  power  of  self-control  that 
after  a  stay  in  the  institution  they  may  appear  so  well 
as  to  be  allowed  to  leave,  and  actually  manage  to  live 
outside  without  doing  anything  to  call  for  their  re- 
committal. They  are  not  cured,  but  if  their  delusions 
are  not  too  strong,  and  their  general  dispositions  good, 
they  may  pass  safely  beyond  the  active  persecutory 
stage  and  act  as  if  they  were  only  eccentric  or  very 
moderately  abnormal  individuals.     It  cannot  be  said, 


368  DEGENERATIVE    INSANITIES. 

however,  that  any  patient  with  delusions  of  persecu- 
tion and  hallucinations  of  hearing  is  safe  to  be  at  large 
without  oversight. 

The  original  paranoiac  may  be  even  more  dangerous 
to  society  or  individuals  than  the  typical  one,  as  is 
shown  by  the  histories  of  some  noted  cases  of  this  kind. 
The  recognition  of  either  form  is  a  matter  of  serious 
importance,  and  it  is  unfortunate,  to  say  the  least,  that 
judges  and  juries  are  so  backward  as  to  their  sequestra- 
tion and  so  ready  to  release  them  from  necessary 
restraint. 

It  should  be  mentioned  here  that  in  the  management 
of  these  patients  any  argument  about  their  delusions, 
or  even  any  reference  to  them,  is  generally  very  in- 
advisable. As  in  every  form  of  insanity,  but  especially 
in  this,  where  the  reasoning  faculties  are  often  so  little 
generally  impaired,  it  is  best  to  treat  the  patients  as 
far  as  possible  as  rational  beings,  and  gain  their  co- 
operation and  good-will  in  the  measures  to  be  taken 
for  their  benefit.  Sometimes  they  appreciate  the 
motives  of  those  in  charge  of  them,  and  maintain  a 
friendly  feeling  toward  them,  but  much  depends  upon 
the  tact  and  good  judgment  of  the  physician  in  their 
management. 


CHAPTER  XIX. 

DEGENERATIVE  INSANITIES   (Continued). 

MORAL  INSANITY. 

Under  the  head  of  "moral  insanity"  we  include  a 
class  that  is  clinically  distinct  enough  to  be  noticed  by 
itself,  though  it  represents  perhaps  two  or  more  dif- 
ferent types  in  its  real  relations  and  nature.  Still 
other  conditions  might  be  classed  by  some  under  this 
head;  thus,  we  have  spoken  already  of  the  moral  in- 
sanity of  a  certain  type  of  hypomania.  The  class  of 
cases  here  described  includes  some  that  may  be  pos- 
sibly closely  related  to  hypomania  or  circular  insanity, 
and  some  that  fall  more  readily  into  the  category  of 
imbecility.  There  is  a  special  form  of  moral  insanity 
sometimes  seen  in  old  alcoholic  cases ;  the  ethical  sense 
seems  altogether  abolished  in  some  of  them,  independ- 
ently of  the  alcoholic  tendencies ;  they  are  absolutely 
immoral  even  when  compelled  by  circumstances  to  be 
perfectly  temperate  for  long  periods  and  when  their 
intellectual  powers  seem  fully  as  active  and  acute  as  in 
the  normal  condition.  These  are  the  alcoholic  cases 
that  are  the  terror  of  asylum  authorities,  and  almost 
the  only  class  of  asylum  inmates  that  is  capable  of 
breeding  plots  and  organizing  conspiracies  among  the 
other  patients.  Another  somewhat  similar  type  is  oc- 
casionally met  with  among  the  epileptics,  but  it  is  here 
much  more  exceptional.  Lombroso,  indeed,  sees  a  fam- 
ily relation  between  epilepsy  and  moral  insanity;  and, 
in  fact,  an  identity,  though  of  somewhat  modified  type. 

What  is  here  considered,  however,  is  different  from 
these,  at  least,  in  its  apparent  beginning.     It  is  not  asso- 

24  369 


370  DEGENERATIVE    INSANITIES, 

ciated  with  epilepsy  or  necessarily  with  any  other  de- 
tectable neurosis  or  psychosis,  though  it  occurs  almost 
invariably  in  degenerates  with  a  bad  family  history 
in  some  neurotic  or  neuropathic  particulars,  and 
usually  in  subjects  presenting  more  or  less  numer- 
ous and  prominent  physical  stigmata,  such  as  cranial 
facial,  aural,  genital,  or  corporeal  defects  or  deform- 
ities. It  is  not  necessarily  accompanied  by  any  symp- 
toms of  mental  deficiency  or  of  the  ordinary  emotional 
abnormalities  of  excitement  or  depression ;  its  essential 
character  is  the  lack  of  the  power  to  recognize  ethical 
distinctions  and  of  that  dictation  or  inhibition  which 
in  its  full  normal  development  we  call  conscience,  in- 
cluding, as  it  does,  the  sense  of  right  and  of  duty. 
Without  this  inhibition,  which  underlies  to  a  degree  all 
the  social  and  altruistic  instincts  and  emotions,  and 
which  is  even  present  in  the  lower  animals,  the  un- 
bridled egoism  has  full  play.  Except  so  far  as  checked 
by  the  intellectual  consideration  of  utility  or  ex- 
pediency, there  is  no  limit  to  the  lengths  it  may  go. 
The  condition  is,  therefore,  one  of  deficiency  of  an  im- 
portant part  of  the  mental  endowment,  and  we  may 
count  it  as  akin  to  imbecility  or  idiocy.  It  might  then 
be  considered  as  an  idiocy  by  deprivation,  accepting 
the  moral  faculty  as  an  additional  higher  sense  the 
organ  of  which  in  the  cerebrum  is  functionally  inactive 
or  wanting.  By  the  same  analogy  we  might  assume 
as  possible  in  these  cases  an  even  higher  development 
intellectually  than  ordinarily,  just  as  the  other  senses 
appear  sometimes  to  act  as  substitutes  and  be  even 
heightened  when  one  is  defective  or  lacking.  Be  this 
as  it  may, — it  is  offered  only  as  a  suggestion, — there 
is  in  some  of  these  cases  no  special  intellectual  de- 
ficiency noticeable,  at  least  not  until  later  in  life,  and 
for  a  time  at  least  the  subject  of  moral  insanity  appears 
bright  and  even  brilliant  in  most  respects.  Ray  has 
given  in  his  "Medical  Jurisprudence  of  Insanity"  a 


MORAL    INSANITY.  37 1 

history  of  such  a  case,  a  brilliant  lawyer,  but  an  abso- 
lutely depraved  and  conscienceless  man,  who  later  in 
life  showed  by  his  insanity  of  acts  that  there  was  with 
the  moral  deprivation  a  serious  lack  of  balance  and 
reaction  between  his  thinking  and  his  acting  capacity. 
These  patients  are,  as  has  been  said,  rare  in  asylums 
unless  in  the  progress  of  the  disorder  their  mental 
faculties  have  generally  begun  to  suffer.  The  symp- 
toms first  appear  in  infancy;  the  moral  development 
does  not  take  place  as  in  normal  children;  they  lack 
natural  affection ;  are  especially  rebellious  to  authority ; 
brutal  and  cruel,  and  unreliable  in  all  respects.  The 
moral  development  of  a  child  is  in  all  cases  largely  a 
matter  of  education,  but  these  cases  lack  the  basis  that 
is  essential  to  a  moral  sense.  This  form  of  moral  in- 
sanity, the  congenital,  may  be  regarded,  when  it  exists 
in  its  fullest  extent,  as  a  moral  idiocy;  there  is  no 
material  for  a  moral  development.  Other  cases  are 
less  extreme;  the  moral  potentialities  are  there  to  a 
certain  extent,  and  while  these  children  are  wayward 
and  hard  to  bring  up  in  a  respectable  way,  they  are 
not  absolutely  incapable  of  learning  self-control  and 
appreciating  the  higher  motives  of  conduct  to  some 
extent.  Many  children  are  to  a  certain  extent  immoral, 
but  these  two  classes,  the  moral  idiots  and  the  moral 
imbeciles,  differ  from  the  mass  in  that  their  original 
capacity  for  moral  education  is  lacking.  As  they  pass 
to  adolescence  the  moral  imbeciles  may  develop  a 
better  moral  sense  and  ability  for  self-control,  so  that 
they  may,  in  adult  life,  become  something  like  normal 
individuals.  They  are  likely,  however,  to  be  always 
moral  weaklings,  quick  to  yield  to  temptations  that 
would  be  resisted  by  a  healthy  minded  man.  When 
these  cases  are  intellectually  bright,  so  that  they  can 
fully  appreciate  utilitarian  considerations  and  control 
conduct  according  to  them,  they  may  become  the 
sharp  unscrupulous  swindlers,  or  business  or  profes- 


372  DEGENERATIVE    INSANITIES. 

sional  men  whose  only  guide  or  restraint  is  expediency 
and  safety.  Such  cases  are,  as  we  all  know,  not  rare, 
and  they  may  possibly  very  often  be  based  on  a  con- 
genital moral  imbecility.  A  very  great  proportion 
of  the  criminals  are  probably  of  this  type,  especially 
the  so-called  "born  criminals,"  which  term,  in  fact, 
implies  just  this  condition. 

The  moral  idiot  is  not  a  modifiable  type  even  by 
training,  and  is  fortunately  a  rare  one.  Such  cases 
exist,  however,  and  it  is  probable  that  in  rare  in- 
stances there  may  be  so  little  intellectual  defect  that 
they  are  able  to  see  the  impolicy  of  indulging  in  such 
extreme  gratifications  of  their  egoistic  and  immoral 
inclinations  as  would  lead  them  into  trouble.  As  a 
rule,  however,  their  self-control  is  defective  somewhere, 
and  their  character  is  manifest,  even  if  they  do  not 
come  under  the  penalties  of  the  law;  they  are  black 
sheep,  ne'er-do-wells,  disgraces  to  their  families,  and 
generally  hopeless  reprobates.  Such  cases  are  some- 
times puzzling  to  place,  but  a  full  and  complete  study 
of  their  history,  family  and  personal,  and  their  physical 
defects  will  enable  one  to  form  an  idea  as  to  their 
mental  condition,  and  in  some  degree  of  their  responsi- 
bility. It  is  not  to  be  understood  that  this  class 
includes  all  criminals,  or  all  even  of  the  habitual 
offenders  against  the  law,  but  that,  though  rare,  it  is 
more  common  than  has  been  generally  believed  is  held 
here  to  be  true.  As  the  moral  functions  are  the 
highest  of  the  mind,  and  are  chiefly  developed  in  the 
human  species,  though  traces  of  them  are  to  be  found 
in  the  lower  animals,  and  are,  therefore,  probably 
among  the  latest  developed,  it  does  not  seem  at  all 
improbable  that,  like  other  recent  requirements  as  yet 
imperfectly  established  in  our  nature,  they  should  fail 
at  times,  and  even  be  extinguished  in  certain  rare 
instances.  Moral  insanity  of  the  moral  imbecility  type 
is  fortunately  not  frequent,  but  the  wonder  is  that  it  is 
as  rare  as  it  is. 


MORAL   INSANITY.  373 

In  women  moral  insanity  of  the  strictly  immoral  kind 
is  probably  rarer  than  in  men;  they  are  less  liable  to 
be  absolutely  deprived  of  all  moral  sense  with  full 
retention  of  intellectual  capacity.  Their  insane  egoism 
is  more  likely  to  be  fully  developed  when  associated 
with  some  pronounced  psychic  or  neuropsychic  de- 
ficiency or  in  hysteric  insanity,  etc.  When  they  are 
moral  imbeciles  or  idiots,  they  are  likely  to  adopt  the 
more  strictly  feminine  forms  of  criminality,  such  as 
prostitution,  rather  than  those  affected  by  the  male 
sex.  It  is  probable  that  among  the  depraved  females 
in  the  cities  there  are  some  that  would  properly  be 
classed  in  this  category. 

The  responsibility  of  the  moral  idiot  is  an  interesting 
question.  There  is  no  doubt  but  that  some  cases  of 
this  kind  whose  intellectual  capacities  are  unimpaired 
can,  if  they  choose,  be  as  good  judges  of  the  expediency 
of  their  acts  as  any  one,  and  are,  therefore,  to  that 
extent  amenable  to  the  law.  They  know  the  conse- 
quences of  their  acts,  and  to  a  certain  extent  may  be 
good  utilitarian  moralists.  The  fact  remains  that  they 
are  imperfect  individuals,  lacking  one  of  the  most 
important  guides  to  conduct,  and  this  should  be  taken 
into  account  in  estimating  their  responsibility.  As  far 
as  the  law  is  intended  as  a  protection  to  society,  they 
need  to  come  under  its  provisions  as  much  as  or  more 
than  ordinary  criminals,  from  the  fact  that  they  lack 
the  basis  of  any  possible  reform. 

One  of  the  latest  writers  on  mental  disease,  MacPher- 
son,  includes  litigious  insanity  under  this  general  head. 
We  have  already  spoken  of  this  type  under  the  general 
head  of  persecutory  paranoia,  where  it  appears  to  us 
to  more  rightfully  belong.  Nevertheless,  there  may 
be  cases  where  moral  insanity  may  manifest  itself  in 
this  symptom  of  litigiousness,  but  it  is  not  the  usual 
full-blown  type.  The  persecutory  litigious  insanity  is 
a  more  limited  aberration,  manifesting  itself  mainly  in 


374  DEGENERATIVE    INSANITIES. 

one  direction,  and  is,  we  believe,  invariably  accom- 
panied with  diverse  insane  conceptions  as  to  the  sub- 
ject's legal  rights — mental  illusions,  if  not  full-fledged 
delusions.  The  moral  deterioration  that  accompanies 
it  is  only  an  incident  of  the  general  condition. 

There  are  other  peculiar  mental  conditions  that  might 
come  under  the  head  of  moral  insanity  more  correctly 
than  persecutory  litigious  paranoia,  but  which  have 
their  special  characters  that  separate  them  from  the 
type.  Among  them  is,  for  example,  the  occasionally 
observed  periodic  vagabondage  in  young  boys  or  even 
children  of  tender  years,  which  is  associated  sometimes 
with  a  very  marked  and  causeless  depravity.  In  a 
case  of  this  kind,  under  our  observation,  a  child  under 
ten  years  of  age,  unusually  bright  for  his  years  and 
generally  a  model  in  behavior,  had  periodic  impulses 
to  run  away,  and  would  sometimes  go  long  distances. 
At  these  periods  also  he  would  steal  money  or  any- 
thing that  took  his  fancy,  would  lie,  and  in  other 
ways  show  a  complete  absence  of  moral  sense  which 
was  not  ordinarily  lacking  in  his  make-up.  After  the 
impulse  was  over  he  could  give  no  explanation  of  his 
conduct,  though  there  was  no  defect  of  memory  or  any 
disturbance  of  the  continuity  of  consciousness  whatever 
so  far  as  could  be  ascertained.  During  these  periods 
he  was  as  complete  an  example  of  apparent  absence 
of  moral  sense  as  is  ever  seen;  between  them  he  was 
a  docile  well-behaved  lad,  rather  exemplary  than  other- 
wise. As  he  grew  up  these  impulses  continued  to 
appear,  and  for  a  long  time;  till  toward  the  end  of 
adolescence,  shortly  after  his  twenty-first  year,  he  under- 
went a  change,  and  became  a  more  reasonable  and 
creditable  person,  though  a  certain  Bohemian  tendency 
was  still  manifest  at  times.  Such  cases  as  this  are  not 
common,  but  they  occur,  and  it  is  difficult  to  properly 
class  them.  Their  periodicity,  or,  rather,  their  irreg- 
ular repetition  of   the  symptoms,  suggests  somewhat 


MORAL    INSANITY.  375 

Lombroso's  epileptic  theory  of  moral  insanity.  They 
are  rarely  met  with  in  asylums,  but  may  be  a  problem 
for  the  purely  medical  counselor  when  they  occur,  and 
one  that  deserves  very  serious  study. 

The  diagnosis  of  moral  insanity,  as  here  limited,  is 
chiefly  from  depravity,  and  can  be  made  only  by  a 
thorough  study  of  the  individual  and  his  history. 
There  is,  however,  in  the  moral  idiot,  lunatic,  or  im- 
becile, whatever  we  may  call  him,  a  sort  of  quality  of 
immorality  that  is  characteristic.  If  morality  consists 
alone,  as  Mercier  says,  in  the  ability  to  forego  indul- 
gence in  one's  egoistic  impulses,  then  the  moral  lunatic 
may  possess  it  to  a  degree,  but  there  is  more  than  that 
in  it.  When  a  man  has  absolutely  no  perception  of 
any  moral  dictation  of  conscience,  or  no  recognition  of 
moral  distinctions  whatever,  he  is  much  more  seriously 
handicapped  as  a  member  of  a  social  organization  than 
is  one  more  normally  constituted.  However  acute  he 
may  be  intellectually,  this  depravation  is  likely,  or 
even  almost  certain,  to  ultimately  damage  his  mental 
health.  We  do  not  believe  that  any  one  so  consti- 
tuted would  be  likely  to  go  through  a  long  life  without 
his  conduct  sooner  or  later  leading  to  a  mental  break- 
down obvious  to  even  an  unskilled  observer.  This 
fact  has  been  the  basis  of  much  of  the  argument  against 
the  existence  of  this  form  of  mental  disorder;  it  has 
been  said  that  observation  of  such  cases  always  sooner 
or  later  revealed  their  intellectual  deficiencies,  hence 
there  was  no  such  thing  as  a  purely  moral  insanity. 
The  fact  that  this  intellectual  morbidity  finally  appears 
is  taken  as  evidence  that  it  has  always  existed,  a  con- 
clusion as  logical  as  it  would  be  to  say  that  because  a 
man  finally  must  die  he  has  been  moribund  all  his  life. 
The  clinical  evidence  of  absence  of  moral  perceptions 
and  inhibitions  in  some  cases  is  overwhelming,  and  the 
other  mental  defects  that  may  or  may  not  be  observed 


37^  DEGENERATIVE    INSANITIES. 

later  have  no  essential  connection  with  it,  at  least  in 
some  stages  or  conditions  of  the  disorder. 

The  prognosis  of  moral  insanity  is  usually  bad. 
Nevertheless  careful  attention  to  its  earliest  signs  in 
childhood  may  ward  it  off,  and  while  we  cannot  create 
a  moral  sense,  we  can  prevent  sometimes  the  oblitera- 
tion of  the  germ  and  cultivate  it  into  something  like 
its  normal  development  if  it  cannot  be  done  completely. 
Moral  training,  good  associations,  and  especially  wise 
and  tactful  control,  are  the  means  of  treatment,  and  in 
some  cases  at  least  there  may  be  hope  of  change  for 
the  better.  This  is  not  to  be  absolutely  given  up  until 
the  individual  has  passed  the  earlier  critical  epochs  of 
infancy  and  adolescence,  as  changes  have  been  observed 
even  at  the  latest  of  these.  The  other  forms  of  moral 
insanity  associated  with  the  various  mental  derange- 
ments already  mentioned  are,  as  a  rule,  episodic,  or 
temporary,  and  need  no  special  mention.  Their  treat- 
ment is  that  of  the  associated  conditions,  on  which, 
also,  their  prognosis  depends. 


CHAPTER  XX. 
IMBECILITY  AND   IDIOCY. 

The  congenital  mental  deficiencies  known  under  the 
designations  of  imbecility  and  idiocy  are  considered, 
as  a  rule,  in  connection  with  insanity  in  works  on 
mental  diseases.  They  are  different  only  in  degree 
from  the  degenerative  insanities  into  which  they 
graduate  through  several  separate  types.  We  can  here 
include  those  cases  that  originate  in  diseases  or  accidents 
in  early  infancy  as  well  as  the  congenital  forms;  they 
differ  only  in  the  stage  of  development  at  their  in- 
cipiency,  and  their  symptoms  and  prognosis  are  prac- 
tically the  same.  The  conditions  of  disease  that  pro- 
duce these  forms  of  mental  defect  are  those  that  inhibit 
or  prevent  the  normal  development  of  the  brain,  such 
as  eclampsia,  hydrocephalus,  meningitis,  etc.  The 
congenital  cases  are  those  of  brain  defects  from  im- 
perfect or  abnormal  development,  as  in  porencephaly, 
macrocephaly,  microcephaly,  abnormal  cortical  de- 
velopment, reversions,  etc. ;  absence  of  important  parts, 
such  as  the  corpus  callosum ;  absence  of  special  lobes, 
particularly  the  frontal  ones ;  defective  cellular  develop- 
ment of  the  cortex,  etc.  To  these  we  must  add  the 
effects  of  autotoxins,  as  in  the  case  of  myxedematic 
idiocy,  where  the  absence  or  imperfect  function  of  the 
thyroid  gland  is  the  cause  of  the  mental  as  well  as  the 
physical  symptoms.  In  some  cases  it  is  impossible  to 
determine  readily  during  life  the  nature  of  the  patho- 
logic process,  and  after  death  the  macroscopic  evidence 
may  be  also  lacking.  It  is  probable  that  in  these  cases 
the  defective  development  of  the  cortical  cells  will  be 
found  to  be  in  fault  when  microscopic  examination  is 

377 


37§  IMBECILITY    AXD    IDIOCY. 

possible.  Besides  this  fetal  or  undeveloped  condition 
of  the  cortical  cells  (Bevan-Lewis,  Middlemass) ,  we 
have  also  an  actual  reduction  of  their  number  (Hanrmar- 
berg),  and  we  can  assume  that,  at  least  in  a  large 
proportion  of  cases  of  imbecility,  a  lack  of  functionally 
active  cortical  cells  is  the  essential  pathologic  condition. 

The  external  physical  stigmata  of  imbecility,  and 
especially  of  idiocy,  are  generally  prominent.  Thus, 
we  have  microcephaly,  on  the  one  hand,  and  the  over- 
grown hydrocephalic  or  hypertrophic  cranium  on  the 
other;  the  peculiar  features  and  misshapen  head  of 
the  Mongolian  type,  the  dull  expressionless  facial  de- 
velopment, the  misshapen  or  defective  auricle,  the 
deformities  of  the  jaws  and  teeth,  facial  and  bodily 
asymmetries,  and  other  characteristics  that  can  be 
noticed  more  in  detail  in  connection  with  the  special 
varieties  to  be  described.  In  the  lesser  degrees  of 
imbecility  these  are  not,  as  a  rule,  so  prominent,  but 
they  usually  exist,  and  are  more  or  less  noticeable  and 
significant. 

Considering  first  the  milder  types  included  under  the 
head  of  imbecility,  we  may  define,  symptomatically, 
the  condition  as  a  state  of  cerebral  defect  characterized 
by  a  more  or  less  limited  intellectual  or  moral  deficiency, 
making  the  subject  to  a  noticeably  greater  or  less 
degree  below  the  average  in  these  respects.  These  are 
the  special  marks  of  imbecility ;  other  brain  defects  are 
not  essential  or  characteristic.  An  individual  may  be 
deprived  of  one  or  more  of  his  or  her  senses ;  in  fact,  so 
many  of  them  may  be  lacking  as  to  largely  cut  off  the 
avenues  for  impressions  from  the  external  world,  as 
in  one  or  two  very  noted  cases,  and  yet  be  very  far 
from  being  an  imbecile.  It  is  the  intellect,  the  judging 
faculty,  or  the  associated  moral  impulse  that  must  be 
affected.  In  most  cases  both  the  intellectual  powers 
and  the  moral  sensibilities  are  affected  together ;  when 
the  latter  alone  suffer  or  are  lacking,   we  have  the 


o 
o 

C 


SEMI-IMBECILES.  379 

typical  moral  insanity,  which,  though  really  a  variety 
of  imbecility,  is  noticed  elsewhere  as  a  separate  type. 

In  many  cases  of  the  milder  or  less  marked  types  of 
imbecility,  the  semi-imbeciles,  as  they  have  been 
called,  there  are  no  very  pronounced  external  stigmata ; 
they  look  and  act  to  a  large  extent  like  normal  indi- 
viduals, and  they  may  be  able  to  fill  a  humble  place  in 
society  where  no  great  demands  are  made  upon  their 
intellectual  powers.  In  infancy  they  may  appear  much 
like  other  children,  and  it  is  only  in  their  later  want  of 
development  that  their  disability  becomes  noticeable. 
They  never  really  pass  beyond  the  stage  of  childhood 
mentally,  though  their  physical  development  may  be 
good.  In  some  respects  they  are  even  below  the  child- 
hood standard;  their  capacity  for  learning  is  very 
limited,  at  least,  in  most  directions,  though  they  may 
show  special  aptitude  in  certain  lines.  Their  sexual 
development  is  marked,  and  they  are  apt  to  be  mastur- 
bators  or  perverts.  Morally  they  are  also  deficient; 
they  are  apt  to  be  unreliable  and  untruthful,  and  sub- 
ject to  fits  of  passion,  and  these  with  their  sexual  im- 
pulses, mentioned  above,  may  make  them  dangerous 
to  society.  Under  judicious  control  it  is  often  pos- 
sible to  make  them  useful  to  a  certain  extent,  and  even 
self-supporting,  but  this  is  not  usually  possible  when 
they  are  left  to  themselves. 

These  are  the  most  familiar  cases,  the  ones  that 
show  their  deficiencies  least.  The  majority  even  of 
these  semi-imbeciles  are  markedly  degenerates,  and 
show  it  in  obvious  physical  signs — misshapen  crania, 
defective  ears,  jaws,  and  teeth,  bodily  asymmetries, 
and  other  stigmata  of  degeneracy.  There  is  usually 
no  very  well-drawn  line  as  regards  the  mental  symp- 
toms between  these  and  those  more  favored  in  a 
physical  point  of  view;  but  the  more  pronounced  the 
bodily  defects,  the  more  marked  are  the  mental  and 
moral  deficiencies.     That  this  is  not  always  so,  does 


380  IMBECILITY    AND    IDIOCY. 

not  affect  the  general  rule,  and  as  we  pass  gradually 
from  the  semi-imbeciles  to  the  imbeciles  in  the  fuller 
sense  of  the  word,  the  exceptions  become  more  rare. 
In  this  latter  class  the  mental  capacity  is  less,  the 
animal  propensities  less  restrained,  and  the  facial  ex- 
pression still  more  indicative  of  vacuity.  Never- 
theless, these  patients  have  a  certain  degree  of  intel- 
lectual vitality;  within  a  limited  scope  they  reason 
correctly,  and  are  still  far  from  being  mental  blanks  or 
falling  within  the  scope  of  the  still  lower  grade  of  defec- 
tives. They  are  generally  docile  if  tactfully  managed, 
and  while  they  are  mostly  incapable  of  strong  affec- 
tions or  natural  emotions,  they  may  become  attached 
to  those  who  care  for  them,  and  even  show  gratitude 
and  be  governed  by  their  relics  of  better  impulses. 

It  has  been  already  remarked  that  while  these  defec- 
tives sometimes  show  striking  abilities  in  some  one 
direction,  their  weakness  in  all  others  is  most  evident. 
These  cases  are  not  very  numerous,  but  they  are  some- 
times seen,  and,  as  a  rule,  the  particular  ability  is  not 
available  for  their  advantage  in  the  struggle  for  ex- 
istence. We  have  known  a  semi-imbecile,  a  rather 
shameless  masturbator,  one  generally  useless  and  un- 
reliable, who  was  so  particularly  gifted  in  prayer  that 
he  often  imposed  on  good  people,  who,  not  knowing 
him  or  his  peculiarities,  thought  him  a  sort  of  saint. 
He  was  fond  of  using  his  accomplishment,  and  fre- 
quented prayer  and  other  meetings,  and  there  he  took 
part,  to  the  discomfort  of  some  who  were  better 
acquainted  with  him.  A  sort  of  religious  tendency 
is  not  uncommon  in  this  class,  and  there  may  be,  in 
some  cases,  a  certain  genuineness  about  it,  but  generally 
they  are  not  capable  of  being  consistently  religious,  as 
are  more  responsible  individuals.  A  peculiar  sense  of 
humor  and  a  sort  of  wit  are  not  uncommon,  and  some 
of  this  class  were  utilized  in  former  times  as  kings'  and 
noblemen's  fools  or  professional  jesters.     Others  show 


SEMI-IMBECILES.  381 

musical  or  arithmetic  talent,  the  well-known  Blind 
Tom  being  one  instance  of  the  former,  showing  that  a 
very  pronounced  degree  of  mental  weakness  is  con- 
sistent with  such  talent. 

These  semi-imbeciles,  when  taken  young,  are  gener- 
ally educable  to  a  certain  extent,  and  may  progress  at 
school  like  other  children  for  a  time.  Their  backward- 
ness soon  becomes  apparent,  however,  and  before  very 
long  they  show  their  mental  incapacity  very  clearly 
in  the  inability  to  follow  any  connective  source  of 
thought,  in  their  weakened  judgment,  and  very  fre- 
quently in  their  moral  as  well  as  mental  deficiencies. 
They  are  cowardly,  irascible,  egotistic  in  a  way,  and 
generally  incapable  and  unreliable. 

We  can  differentiate  the  grades  of  mental  deficiency 
as  follows :  The  semi-imbecile  is  a  case  of  mental  weak- 
ness ;  the  faculties  exist,  but  are  not  up  to  the  normal 
standard  of  even  average  mediocrity.  The  will  is 
especially  deficient  and  the  higher  inhibitions  are 
largely  wanting,  though  in  certain  special  directions 
the  development  may  be  high.  The  complete  imbecile 
is  a  still  lower  grade,  but  the  mental  faculties  are  still 
in  evidence  to  a  certain  extent.  It  is  an  extreme 
debility,  not  an  abolishment  of  them,  that  we  find  in 
these  unfortunates.  In  the  idiot,  on  the  other  hand, 
we  have  the  lowest  grade,  with  a  complete  abolition  or 
suppression  of  the  intellectual  and  moral  faculties; 
and  if  there  remain  any  traces,  they  are  exceptional, 
and  limited  to  one  or  two  of  the  special  mental  facul- 
ties. There  is  a  wide  range,  it  is  true,  amongst 
idiots,  in  their  capability  of  being  instructed  in  some 
simple  matters,  but  in  all  we  find  the  absence  instead 
of  the  mere  weakening  of  the  intellect.  In  the  higher 
grades  there  may  be  some  signs  of  simple  mental 
action,  limited  to  a  few  points;  they  may  even  have 
the  command  of  a  few  words  or  phrases,  and  can  even 
be  taught  to  observe  some  of  the  conventionalities  and 


382  IMBECILITY    AND    IDIOCY. 

decencies  of  civilized  life,  and  to  know  and  even  show 
some  regard  for  those  who  have  the  care  of  them ;  they 
may  even  be  taught  some  simple  tasks  which  they 
do  under  the  constant  supervision  of  their  caretakers, 
but  they  go  no  further,  and  are  utterly  incapable  of 
consecutive  reasoning  even  in  simple  matters,  or  of 
continued  attention  to  anything.  In  almost  all  cases 
their  bodily  stigmata  are  marked ;  they  have  deformed 
crania  and  features,  their  limbs  are  misshapen,  bodily 
asymmetries  exist,  they  very  commonly  have  excessive 
or  imperfect  development  of  the  genitals,  and  their 
appetites  are  abnormal  and  uncontrolled  by  any  higher 
inhibitions.  To  a  certain  extent  they  are  susceptible 
to  discipline,  but  they  are  much  like  the  lower  animals 
in  their  tendencies  without  their  special  adaptation  to 
their  environment.  They  are  governed  by  their  in- 
stincts rather  than  by  any  judgment  even  in  elementary 
matters,  or  by  any  higher  feelings  or  emotions. 

The  idiot  is  simply  a  being  without  ideas,  an  in- 
dividual in  whom  the  intellect  is  absolutely  unde- 
veloped. He  differs  from  the  demented  patient  in  that 
the  latter  has  a  developed  but  diseased  brain;  while 
the  idiot  has  an  undeveloped  or  imperfect  one.  In  the 
dement  there  are  generally  more  or  less  relics  remaining 
of  a  normal  past  which  the  idiot  has  not.  Clinically 
also  they  differ;  the  dement  may  be  stupid,  helpless, 
and  speechless,  but  he  is  liable  to  have  brighter  inter- 
vals, and  even  recovery  may  occur,  while  this  is  not 
possible  with  the  complete  idiot.  Their  physical  stig- 
mata differ  also ;  in  the  idiot  we  have,  according  to  the 
type,  the  microcephalic  or  macrocephalic  head,  or 
deformed  limbs,  etc.,  which  are  wanting  in  the  de- 
mented patient.  The  two  conditions  are  only  similar 
in  the  absence  of  intellectual  activities  and  its  con- 
sequences ;  in  all  other  respects  they  are  widely  different 
from  each  other. 

There   have   been   several   classifications    of   idiots 


IDIOTS.  383 

according  to  their  causation,  special  characteristics, 
and  symptoms,  but  a  brief  description  of  the  more 
prominent  types  will  suffice  here.  The  ordinary 
congenital  idiot  is  perhaps  most  frequently  met 
with.  In  this  type  the  physical  development  may  be 
fairly  good ;  the  cranium  well  developed  as  to  size  and 
not  specially  abnormal  in  contour,  but  the  features 
are  generally  heavy  and  expressionless,  sometimes  still 
infantile  in  conformation  to  a  certain  extent;  the  jaws 
are  apt  to  be  misshapen,  very  often  what  the  dentists 
call  the  V  or  the  saddle  shape,  the  teeth  irregular  and 
defective,  the  ears  misshapen  and  misplaced,  the  palate 
high  arched.  This  last  deformity  has  been  especially 
noted  as  of  importance  by  writers,  but  it  is  not  exclu- 
sively associated  with  idiocy,  though  more  frequent 
than  in  the  normal  population.  Other  bodily  defects 
are  sometimes  present ;  badly  shaped  or  proportioned 
limbs  and  abnormalities  of  the  sexual  organs,  cryptor- 
chidism, and  lack  of  hair  on  the  genitals  and  absence  of 
the  beard  in  the  adult  idiot  are  not  infrequent.  Only 
rarely  do  we  meet  with  children  that  are  physically 
well  formed  throughout  and  with  handsomely  molded 
though  expressionless  features,  but  such  do  sometimes 
occur.  We  have  seen  idiots  that  would  be  considered 
handsome  children  but  for  their  dull  aspect,  drooling, 
and  generally  untidy  habits. 

A  special  variety  of  the  congenital  idiot  has  been 
specially  designated,  from  its  peculiar  physiognomy, 
the  Mongolian  type.  In  these  we  have  a  low  stature, 
rather  a  gross  figure,  a  broad  face  with  a  depressed  nasal 
bridge  and  obliquely  set  eyes ;  hence  the  special  designa- 
tion. The  tongue  is  generally  large  and  the  fungiform 
papilla?  marked,  so  that  it  presents  a  roughened  appear- 
ance. The  genitals  are  apt  to  be  undeveloped,  the 
testicles  small  or  undescended.  The  skull  is  commonly 
flattened  anteroposteriorly,  but  is  not  specially  less  in 
size  than  in  the  normal  individual.     These  cases  are 


384  IMBECILITY    AND    IDIOCY. 

often  lively  and  less  obtuse  than  some  of  the  other 
idiots,  but  their  intelligence  is  very  limited,  as  a  rule. 
We  have  seen  this  general  physical  type  in  one  or  two 
rather  bright  individuals,  so  that  it  is  not  altogether 
peculiar  to  idiocy,  though  it  is  very  characteristic  of  a 
certain  type. 

Another  characteristic  form  of  congenital  idiocy  is 
the  microcephalic.  Here,  as  the  name  implies,  the 
most  prominent  feature  is  the  smallness  of  the  cranium, 
which  is  noticeable  at  sight.  The  actual  size  of  the 
head  varies,  and  there  is  no  exact  definition  of  what 
is  a  microcephal.  Ireland  gives  as  an  approximate 
limit  1 7  inches  in  circumference ;  all  below  that  he  would 
consider  microcephalous.  This  is  perhaps  the  rarest 
form  of  idiocy,  but  as  it  is  the  most  striking,  the  marked 
cases  of  this  type  have  received  much  attention.  As  a 
rule,  these  idiots  are  undersized ;  their  bodily  develop- 
ment may  be  fair ;  they  generally  have  good  control  of 
their  movements.  Their  grade  of  intelligence  varies ; 
some  of  them  are  imbeciles  rather  than  idiots;  others 
are  complete  idiots,  unable  to  care  for  themselves,  and 
would  soon  perish  if  not  fed  and  protected.  This  class 
includes  some  cases  that  are  educable  up  to  a  certain 
degree;  they  can  be  taught  to  talk  and  even  to  read 
in  some  cases,  but  their  limit  is  soon  reached,  and  their 
development  is  not  more  than  that  of  a  child  of  eight 
or  ten  at  the  best.  In  many  more  cases  they  are  in- 
capable of  any  considerable  degree  of  education.  .  As 
in  the  ordinary  congenital  idiot,  the  symptoms  appear 
from  birth,  and  there  is  no  sudden  or  gradual  post-natal 
mental  deterioration. 

In  these  cases  the  brain  is  small,  as  might  be  ex- 
pected, and  it  may  be  very  imperfect  in  its  convolu- 
tional  arrangement.  The  cerebellum  is  liable  to  be 
proportionately  better  developed  than  the  cerebrum, 
which  may  explain  the  good  coordination  and  motor 
power.     It  is  said  that  the  fontanels  are  earlier  closed 


IDIOTS.  385 

in  these  than  in  other  cases,  and  a  premature  closure  of 
the  sutures  has  been  given  as  a  reason  to  explain  the 
non-development  of  the  brain  and  skull.  This  has  sug- 
gested the  idea  of  surgical  interference,  which  will  be 
noticed  under  the  head  of  treatment  later  on. 

The  acquired  forms  of  idiocy,  including  under  this 
head  all  cases  where  the  deficiencies  become  apparent 
after  the  first  months  of  life,  are  numerous.  Some  of 
these  are,  properly  speaking,  not  acquired,  as  they 
are  due  to  defects  that  only  become  actively  efficient 
at  a  certain  stage  of  development.  The  distinction  is 
not  always  a  valid  one,  moreover,  as  many  of  the 
causes  begin  to  act  before  birth,  though  their  full  effects 
are  not  manifest  till  some  time  after.  Hydrocephalus 
and  porencephaly  may  begin  in  the  antenatal  condi- 
tion; injuries  to  the  brain  may  and  often  do  occur  at 
birth,  when,  also,  may  be  laid  the  foundations  for 
subsequent  epilepsy  and  paralysis,  and  the  goitrous 
lesion  of  cretinism  may  appear  at  the  same  time.  As 
a  rule,  however,  hydrocephalic,  hypertrophic,  epileptic, 
and  inflammatory  and  cretinoid  idiocies  make  their  first 
recognizable  appearance  after  birth  and  during  the 
first  few  months  of  infancy.  The  same  is  true  of  the 
family  forms  of  paralytic  idiocy  and  the  amaurotic 
type  described  by  Sachs.  In  all  these  the  child  appears 
generally  normal  at  birth  and  for  some  little  time  after ; 
then  the  symptoms  of  idiocy  appear  and  continue 
during  life. 

Hydrocephalus  does  not  necessarily  destroy  the 
mental  activities;  there  are  notable  cases  where  the 
subject  is  not  so  defective  intellectually  as  to  be  classed 
either  with  idiots  or  imbeciles.  A  very  slight  degree 
of  hydrocephalus  in  infancy  has  been  thought  in  some 
instances — that  of  Helmholtz,  for  example — to  have 
favored  subsequent  mental  development.  Most  com- 
monly, however,  a  marked  degree  of  this  condition  is 
attended  with  mental  enfeeblement,  and  sometimes  is 
25 


386  IMBECILITY    AND    IDIOCY. 

the  cause  of  more  or  less  complete  idiocy.  The  idiots 
of  this  class  are  generally  docile  and  inactive;  they  are 
apt  to  be  scrofulous  and  short-lived.  It  is  easy  to 
admit  the  consequences  of  the  swelling  and  pressure 
and  the  derangement  of  the  anatomy  of  the  brain  in 
advanced  hydrocephalus  as  causing  idiocy,  and  the 
only  wonder  is  that  its  effects  are  not  always  so  marked. 

There  have  been  several  forms  of  idiocy  described 
associated  with  structural  defects  of  the  cerebrum, 
generally  with  eclamptic  or  epileptoid  symptoms. 
Some  of  them  may  be  considered  only  early  cases  of 
epileptic  dementia,  and  of  hemiplegic  dementia  occur- 
ring at  a  very  early  age,  the  brain  lesion  affecting  its 
structure  and  arresting  its  development.  In  some  of 
these  cases  the  direct  pathology  and  etiology  are 
obscure,  but  in  all  we  can  count  on  the  existence  of 
cortical  arrest;  and  probably  if  the  Hammerberg 
method  of  cell  enumeration  were  employed,  we  would 
find  the  cortical  cells  less  abundant  than  normal,  and 
probably  also  exhibiting  other  defects. 

Cretinism  is  a  form  of  disease  depending  upon  tox- 
emia due  to  deficient  or  perverted  function  of  the 
thyroid  gland.  The  mental  symptoms  associated 
with  it  range  through  all  the  grades  of  imbecility 
to  complete  idiocy.  It  is  rarely  congenital,  but  gener- 
ally makes  its  first  appearance  quite  early  in  life, 
and  is  subject  to  amelioration  if  treatment  is  in- 
stituted sufficiently  early.  It  is  rare  in  this  country, 
but  is  common  in  some  mountainous  regions  of  Europe, 
where  it  seems  to  flourish  most  in  secluded  valleys  and 
in  conditions  of  bad  hygiene.  It  has  been  attributed 
to  defects  in  water  or  soil,  to  unhealthy  modes  of  life, 
to  geologic  conditions,  to  close  breeding  by  inter- 
marriage, etc.,  but  its  causes  are  still  obscure.  One 
thing  is  certain :  it  is  endemic  in  certain  regions,  and  it 
may  be  due  to  some  telluric  cause,  if  not  to  a  germ. 
A    closely    related    form    is,    however,    not    specially 


IDIOTS.  387 

limited  to  any  region — the  so-called  myxedematous 
idiocy,  which  unquestionably  has  its  origin  in  the 
absence  or  functional  inactivity  of  the  thyroid.  This 
is  often  called  sporadic  cretinism,  and  is  limited  to  no 
special  region.  The  disease  generally  makes  its  ap- 
pearance during  the  first  year  of  life;  the  children 
become  stupid  and  indifferent,  and  as  they  grow  up 
their  features  become  heavy  and  coarse,  the  limbs 
short  and  stumpy,  the  figure  squat,  the  tongue  large, 
the  skin  dry  and  scaly,  but  swollen-appearing,  the  hair 
scanty,  the  lips  thick,  and  the  general  appearance 
stupid  and  repulsive.  The  skull  is  not  necessarily 
misshapen  and  the  hands  are  fairly  proportioned,  but 
there  are  often  swellings  of  the  neck,  and  the  thyroid  is 
absent  or  atrophied.  These  idiots  are  generally  of  the 
lower  grade,  with  little  sign  of  intelligence,  though 
sometimes  there  may  be  some  indications  of  intellect 
apparent.  They  are  usually  docile,  but  this  is  mainly 
due  to  their  stupidity.  Altogether  they  are  one  of  the 
more  repulsive  types,  but  they  have  a  special  interest 
owing  to  their  possibilities  of  improvement.  This  will 
be  spoken  of  more  fully  under  the  head  of  treatment. 

The  diagnosis  of  idiocy  and  imbecility  is  simple, 
only  the  very  mildest  type  of  the  latter  affording  any 
difficulty.  When  the  history  of  the  patient  is  at  hand, 
the  question  is  always  easily  solved  in  every  case. 
There  is  little  danger  of  confounding  it  with  dementia, 
the  marked  physical  stigmata  alone  in  most  cases 
sufficing  for  the  differentiation. 

The  prognosis  is  not  generally  favorable,  except  as 
to  amelioration  in  varying  degrees,  and  this  differs  in 
different  types.  The  congenital  idiots  and  imbeciles 
are  less  hopeful  than  the  myxedematous  cases.  In 
quite  a  large  proportion  a  certain  degree  of  improve- 
ment is  possible,  but  only  under  special  care  and  at  the 
expense  of  a  vast  amount  of  patient  attention  and 
instruction.     The   most   brilliant   successes   are   those 


388  IMBECILITY    AND    IDIOCY. 

striking  ones,  like  Laura  Bridgeman,  which  are  really, 
however,  not  idiots  at  all,  but  normal  individuals  de- 
prived b}^  disease  of  some  of  the  main  channels  of 
impressions  upon  the  mind.  If  these  channels  are 
opened  up,  even  at  a  comparatively  advanced  age, 
they  may,  like  Laura  Bridgeman  or  Helen  Kellar,  de- 
velop a  very  high  grade  of  intelligence. 

The  treatment  of  idiocy  and  imbecility  is  mainly 
pedagogic,  but  the  more  knowledge  the  teacher  pos- 
sesses of  their  physical  deficiencies  and  their  physio- 
logic psychology,  the  better.  Hence  it  is  best  carried 
on  by  specialists  in  an  institution  designed  for  their 
care.  It  is  a  hardship  and  a  worry  to  associate  even 
semi-imbeciles  in  schools  with  normal  children,  as  they 
are  liable  to  have  to  suffer  for  their  deficiencies. 
Special  training  and  capacity  are  needed  to  bring  out 
what  intellectual  power  they  possess,  but  a  certain 
proportion  can  be  educated  and  fitted  to  fill  a  place  in 
society,  though  not  a  high  one.  Yet  certain  imbeciles 
may  show  special  talents ;  perhaps  music  is  the  line  in 
which  the  greater  number  show  some  capacity;  Dr. 
Ireland  says  that  most  idiots  who  pay  any  attention 
to  sound  have  an  ear  for  music.  Others  may  show 
special  mechanical  ability,  and  still  others  have  had 
remarkable  abilities  in  limited  directions  otherwise. 
Many  idiots  are,  nevertheless,  absolutely  incapable  of 
any  degree  of  education,  not  even  enough  to  care  for 
their  simplest  wants. 

It  is  important  that,  in  order  to  develop  any  pos- 
sible latent  talent  in  the  idiot  or  the  imbecile,  the 
training  be  begun  early,  before  habits  and  time  have 
fixed  their  tendencies  and  spoiled  the  chances  of  im- 
provement. In  myxedematous  idiocy  the  thyroid 
treatment  is  almost  a  specific,  but  in  these  cases  it  is 
better  that  the  medication  be  begun  when  the  patient 
is  young.  The  physical  improvement  is  nearly  always 
very  marked,  and  while  the  mental  improvement  may 


TREATMENT.  389 

be  less  marked  and  slower,  it,  however,  develops  to  a 
certain  extent.  In  cretins,  while  it  is  theoretically 
indicated,  this  treatment  is  not  so  generally  successful. 
In  any  case  it  may  be  necessary  to  keep  it  up  or  repeat 
the  treatment  frequently  for  a  long  time  or  during  life. 
It  should  be  commenced  cautiously  in  moderate  doses, 
and  its  effects  on  the  system  carefully  watched  in  these 
as  in  all  other  cases  where  it  is  employed.  In  other 
forms  it  is  not  specially  useful. 

Something  may  be  said  here  of  the  surgical  treatment 
of  idiocy.  It  has  been  suggested  that  the  cranium 
ossifying  too  early  has  checked  the  development  of  the 
brain,  and  an  operation  relieving  pressure  has  been 
proposed  and  tried  in  a  number  of  instances.  The 
theory  has  not  been  generally  accepted  by  the  best 
authorities,  and  a  critical  discussion  of  the  operation 
and  its  literature  in  a  recent  memoir  by  Lowenstein  * 
shows  that  the  results  are  not  such  as  to  commend  it. 

Imbeciles  may  be  fairly  long-lived,  but  their  in- 
ability to  care  for  themselves  properly  is  against  this 
being  the  rule,  and  idiots,  as  might  be  supposed  from 
their  numerous  physical  defects,  are  not  likely  to  reach 
old  age.  They  often  suffer  from  cardiac  disease,  and 
their  small  and  weak  hearts  are  very  possibly,  as  Ireland 
suggests,  in  some  degree  the  cause  of  their  cerebral 
deficiencies  by  reason  of  an  insufficient  blood-supply 
to  the  brain.  Many  hydrocephalous  children  die  in 
infancy,  and  convulsions  and  other  nervous  diseases 
are  fatal  to  many  others.  The  idiot  stands  at  the 
lower  end  of  the  scale  of  defectives,  physically  as  well 
as  mentally,  and  is  the  more  likely  to  succumb  to  what 
a  more  perfect  organization  would  naturally  survive. 

*  Brim's  "  Beitrage,"  xxvi.     I.    (3.) 


CHAPTER  XXI. 

BORDERLAND  AND  EPISODIC  STATES, 

OBSESSIONS,  PHOBIAS,  IMPULSES. 

The  conditions  of  mental  aberration  here  considered 
comprise  quite  a  wide  range  of  symptoms  of  equally 
varying  gravity,  some  of  them  comparatively  trivial 
and  not  specially  of  serious  import,  while  others  are 
indicative  of  marked  degrees  of  degeneracy  and  are 
formidable  in  themselves.  They  agree  only  in  the  fact 
that  they  do  not  fall  readily  into  any  of  the  special 
forms  of  insanity  described,  that  in  them  the  intelli- 
gence is  not  materially  implicated,  and  that  in  all  there 
is  a  decided  nervous  weakness  involving  more  or  less 
that  mental  function  that  we  call  the  will.  Except  in 
their  most  pronounced  development,  or  when  associated 
with  other  clearly  insane  manifestations,  they  seldom 
are  met  with  in  the  asylums,  but  they  are  common  in 
the  experiences  of  outside  practitioners,  and  in  some 
of  their  mildest  forms  can  almost  be  said  to  be  matters 
of  common  experience.  There  are  probably  few  normal 
individuals  who  have  not  felt  at  least  a  suggestion  of  a 
morbid  impulse  under  certain  favoring  conditions,  or 
had  a  haunting  idea  that  was  not  far  from  an  obsession 
at  some  time  in  their  lives.  They  comprise  a  true 
borderland  between  mental  sanity  and  disease,  and  are 
found  well  over  both  sides  of  the  indefinite  dividing- 
line  that  separates  these  states. 

The  peculiarities  and  oddities  of  some  persons  that 
go  under  the  general  names  of  eccentricities,  crankiness, 
etc.,  have  been  already  incidentally  noticed  in  connec- 
tion with  certain  forms  of  insanity,   etc.     These  are 

390 


OBSESSIONS,    PHOBIAS,    IMPULSES.  391 

generally  indications  of  degeneracy,  and  in  some  cases 
the  individuals  are  really  only  mild  instances  of  some 
form  of  mental  derangement — circular  or  periodic  in- 
sanity or  original  paranoia;  in  others  the  apparent 
eccentricities  are  only  racial  peculiarities  or  the  results 
of  early  training  emphasized  by  a  special  environment, 
as  suggested  by  Kiernan  in  the  case  of  Thomas  Carlyle. 
There  is,  however,  a  certain  number  of  eccentrics 
whose  aberrations  cannot  be  accounted  for  in  either  of 
these  ways,  and  who  make  up  the  class  of  disequilib- 
rates,  or,  in  common  language,  "cranks."  While  they 
may  never  become  actually  insane  in  the  legal  or 
medical  sense  of  the  term,  they  are  frequently  the 
descendants  or  progenitors  of  lunatics,  and  the  family 
history  shows  their  real  position  on  the  borderland  of 
mental  alienation.  These  individuals  are  often  men- 
tally brilliant  in  some  directions;  many  of  the  un- 
balanced or  irregular  geniuses  are  of  this  type.  Others 
are  mediocre  in  talent,  and  only  exhibit  a  lack  of 
mental  balance  that  handicaps  them  in  the  competition 
and  struggle  of  existence.  A  very  common  peculiarity 
is  in  their  writing — the  undue  use  of  italics,  for  ex- 
ample, so  characteristic  of  a  certain  class  of  these  dis- 
equilibrates.  It  is  almost  impossible,  however,  to 
definitely  define  them,  as  their  symptoms  and  pecu- 
liarities are  manifold,  and  they  shade  off  imperceptibly 
into  the  average  individuals.  It  is  only  when  their 
abnormalities  are  rather  striking  that  they  can  be 
reckoned  as  belonging  properly  on  the  borderland  of 
insanity.  It  is  rare  for  these  persons  to  be  in  any  sense 
dangerous  or  to  require  sequestration,  except  when,  as 
sometimes  happens,  the  degenerative  predisposition 
causes  them  to  succumb  more  readily  than  others  to 
attacks  of  actual  mental  derangement. 

The  class  of  eccentrics  or  cranks  stand  on  the  border- 
land of  insanity  by  reason  of  their  mental  twist  or 
deficiency ;  they  are  for  the  most  part  nearer  the  original 


392  BORDERLAND    AND    EPISODIC    STATES. 

paranoiacs  and  the  imbeciles  than  to  other  types  of 
mental  disease.  They  hardly  come  within  the  scope 
of  the  present  chapter,  which  mainly  treats  of  a  quite 
different  class  of  borderland  conditions  that  are  for 
the  most  part  comprehended  under  the  head  of  obses- 
sions— a  French  term  which  has  become  naturalized 
in  our  language  as  the  most  expressive  and  descriptive 
for  these  states.  The  term  "obsession"  is  here  used 
in  its  wider  sense  as  covering  all  the  will  defects  char- 
acteristic of  these  conditions,  not  in  the  narrower  sense 
of  simple  imperative  ideas,  and  not  including  all  the 
impulsions  and  aboulias  as  well.  All  these  symptoms, 
whether  affecting  directly  the  emotions  or  the  intellect, 
are  essentially  defects  of  the  will ;  they  have  in  common 
the  character  of  being  recognized  as  morbid  by  the 
subject  himself,  and  they  have  been  classed  by  recent 
writers  as  belonging  to  the  neurasthenias,  as  being 
symptoms  of  functional  weakness  of  the  higher  cortical 
centers.  They  are  commonly  said  to  be  usually 
hereditary,  but  in  our  observation  this  is  not  by  any 
means  always  the  case.  Practically  they  are  only 
exaggerations  of  the  experiences  of  most,  if  not  all, 
normal  individuals,  and  it  is  only  through  the  degree 
of  this  exaggeration  that  they  carry  their  victims  over 
on  the  borderland  of  mental  health.  We  are  all  of  us 
subject  to  morbid  impulses  and  to  besetting  mental 
conceptions  or  obsessions,  but  with  most  of  us  these 
are  only  transient,  and  are  fully  controlled  by  the  in- 
telligent will.  It  is  only  in  certain  conditions  of 
nervous  exhaustion  or  in  persons  who  are  naturally 
defective  that  these  defects  become  actual  obsessions. 
We  must  remember,  also,  that  a  certain  degree  of 
defectiveness  is  the  rule;  no  one  is  perfect  physically 
or  mentally,  and  the  individual  who  is  perfectly  free 
from  all  stigmata  of  degeneracy  probably  does  not 
exist.  It  is  this  inherent  element  of  degeneracy  in  us 
all  that  comes  into  play,  so  to  speak,  in  these  neuras- 


OBSESSIONS    OF    INDECISION.  393 

thenic  manifestations  that  lie  on  the  borderland  of 
mental  disease. 

Following  the  classification  of  Regis,  whose  chapter 
on  these  symptoms  is  one  of  the  best  general  summaries 
of  the  subject,  we  can  divide  the  obsessions  first  into 
impulsive  types,  where  the  suggestion  or  feeling  that 
lies  at  the  basis  of  these  symptoms  is  not  controlled  by 
the  inhibitory  action  of  the  will.  Under  ordinary 
healthy  conditions  we  have  the  power  of  choice  in  our 
ideas  and  resulting  actions;  no  one  of  them  becomes 
predominant  so  that  we  cannot  substitute  for  it  an- 
other. In  this  obsession  the  victim  of  the  impulsion 
is  impelled  to  act  and  think  against  his  judgment,  and 
in  extreme  cases,  where  the  volition  is  altogether  dis- 
abled, may  do  the  most  absurd  or  even  criminal  acts, 
or  be  tormented  with  the  most  unreasonable  fears  or 
doubt,  being  all  the  time  fully  conscious  of  their 
absurdity  and  impropriety.  Regis  divides  these  im- 
pulsions or  impulsive  obsessions  into  (i)  the  obsessions 
of  indecision;  (2)  the  obsessions  of  fear  (phobias) ;  and 
(3)  the  irresistible  propensities  or  morbid  impulses. 

Obsessions  of  Indecision. — The  most  typical  form 
of  this  class  is  the  folie  du  doute,  or  doubting  insanity, 
as  it  has  been  called.  In  its  mildest  form  it  is  by  no 
means  uncommon;  it  may  exist  merely  as  a  tendency 
to  question  one's  acts — to  be  troubled  with  an  un- 
certainty as  to  whether  one  has  locked  a  door  as  he 
should,  for  example.  Another  form  is  what  the  Ger- 
mans have  called  Grubelsucht,  or  metaphysical  mania, 
where  the  individual  distresses  himself  over  abstract 
or  ridiculous  questions.  Still  others  are  in  constant 
distress  for  fear  that  they  have  mistaken  the  address 
on  a  letter  that  they  have  sent,  or  some  equally  trivial 
matter.  In  one  case  observed  the  patient  would  spend 
hours  in  going  back  and  forth  before  starting  any- 
where, each  start  being  balked  by  the  fear  that  some- 
thing or  other  had  not  been  done  that  ought  to  have 


394  BORDERLAND    AND    EPISODIC    STATES. 

been  done.  Even  the  going  up  and  down  stairs  to  and 
from  his  room  was  interrupted  the  same  way ;  he  would 
go  back  and  forth  indefinitely  until  stopped  by  almost 
the  use  of  force.  Still  others  are  troubled  with  reli- 
gious scruples;  they  have  an  abiding  fear  that  they 
have  committed  some  sin,  possibly  a  trivial  one,  but 
it  may  occupy  their  mind  almost  to  the  exclusion  of 
all  other  ideas.  The  varieties  of  these  obsessions  of 
indecision  are  infinite;  anything  in  regard  to  which  it 
is  possible  to  raise  a  doubt  may  be  their  incitation. 
Some  patients  distress  themselves  for  fear  they  have 
been  gu:lty  of  some  impropriety,  perhaps  some  trivial 
mistake  in  etiquette;  others  are  equally  worried  for 
fear  that  in  some  of  their  acts  they  may  do  something 
in  the  wrong  way — the  tying  of  a  cravat  or  parting  of 
the  hair,  the  form  of  greeting  or  parting,  etc.,  may  any 
of  them  be  the  subject  of  their  worries.  Perhaps  the 
most  frequent  form  is  the  question  that  arises  as  to 
whether  one  has  performed  certain  duties  or  taken 
certain  precautions,  such  as  leaving  things  in  their 
proper  place,  locking  doors,  turning  out  the  gas,  etc., 
and  even  in  the  milder  types  which  some  of  us  may 
have  personally  experienced,  the  individual  will  go 
back  on  his  tracks  over  and  over  again  before  he  can 
free  himself  from  the  obsession.  Closely  allied  to  this 
type  are  the  crack-steppers  and  the  counters,  etc., 
who  feel  uneasy  if  they  fail  to  note  the  number  of  posts 
they  pass  or  if  they  step  off  certain  definite  lines  in 
their  walks. 

In  its  severer  manifestations  this  doubting  psychosis 
may  be  a  very  serious  matter ;  it  may  occur  paroxysm- 
ally  and  be  accompanied  by  precordial  pains,  headaches, 
etc.  The  common  delusion  of  having  committed  the 
unpardonable  sin  in  melancholiacs  has  some  resem- 
blance to  some  of  the  doubts  and  mistrusts,  but  the 
real  melancholiac  is  a  different  sort  of  case.  These 
neurasthenic  obsessions  are  not  real  delusions ;  the  sub- 


OBSESSIONS    OF    FEAR.  395 

ject  has  a  perfectly  clear  intellectual  comprehension 
of  his  unreasonableness ;  they  are  simply  ideas  or  feel- 
ings that  he  cannot  get  rid  of  at  the  time.  It  is  in  the 
milder  manifestation,  however,  that  these  obsessions 
of  indecision  are  most  commonly  observed,  and  in 
many  cases  they  hardly  affect  the  normal  life  of  the 
individual,  and  to  a  slight  extent  they  have  been  a 
part  of  the  experience  of  very  many  otherwise  mentally 
healthy  persons. 

The  phobias,  or  obsessions  of  fear,  constitute  a  more 
obviously  abnormal  class  of  symptoms,  and  are  much 
less  common  than  the  obsessions  of  doubt.  In  these 
the  patient  suffers  from  an  uncontrollable  dread, 
usually  confined  to  a  single  object  or  class  of  objects. 
In  some  directions  it  borders  on  the  class  just  described ; 
as,  for  example,  in  the  so-called  mysophobia,  or  fear 
of  dirt,  where  the  continual  washings  may  be  inter- 
preted often  as  the  result  of  an  obsession  of  doubt  as  to 
their  completeness  as  well  as  to  the  fear  of  defilement 
to  which  they  are  usually  credited.  In  fact,  in  this  as 
well  as  in  some  other  ways  the  two  conditions  overlap, 
so  to  speak.  But  the  fully  developed  obsessions  of 
fear  are  a  step  beyond  those  of  doubt  either  as  neuras- 
thenic symptoms  or  mental  degenerative  stigmata. 
The  forms  they  may  take  are,  however,  almost  as 
numerous.  We  have,  thus,  the  fear  of  open  places 
(agoraphobia),  in  which  the  patient  cannot  cross  a 
square  or  even  the  street;  and  its  opposite  (claustro- 
phobia), where  the  same  sort  of  dread  is  excited  by 
being  in  an  inclosed  space.  A  large  number  of  other 
forms  have  been  described,  such  as  astrophobia  (fear 
of  lightning),  cremnophobia  (fear  of  precipices),  fear 
of  blood  (hematophobia) ,  etc.,  all  only  manifestations 
of  a  special  form  or  type  taken  by  this  neurasthenic 
dread.  The  origin  of  these  fears  is  simply  explained: 
they  are  results  of  ideas  that  would  leave  only  fleeting 
impressions  on  a  healthy  brain,  but  which  leave  an 


396  BORDERLAND    AND    EPISODIC    STATES. 

exaggerated  and  lasting  trace  on  the  asthenic  organ. 
They  may  originate  with  some  special  experience :  an 
apparently  narrow  escape  from  being  run  over  may 
be  the  inciting  cause  of  an  agoraphobia;  a  sudden 
morbid  impulse  or  suggestion  to  throw  one's  self  down 
ma}7  be  the  cause  of  a  phobia  as  regards  all  high  places. 
In  all  cases  it  is  the  weakened  inhibition  that  is  at 
fault.  It  is  easy  to  see  how  almost  any  variety  of 
obsessions  of  dread  may  thus  arise,  and  most  of  us  can, 
from  our  own  experience,  appreciate  their  possibility. 

Morbid  impulse,  or  obsession  propension,  is  still  an- 
other modality  of  the  same  general  type  of  neurasthenic 
defect  of  mental  and  emotional  control,  the  existence 
and  modus  operandi  of  which  can  be  readily  appreciated 
from  one's  own  experience.  Most  of  us  have  experi- 
enced at  times  a  morbid  impulse  to  do  something  of 
which  our  better  judgment  disapproved,  and  it  is  only 
in  these  cases  where  the  impulsions  are  so  strong  as  to 
cause  distress  or  become  irresistible  that  they  are 
really  on  the  borderland  or  fall  under  the  head  of  the 
subject  of  this  chapter.  The)7  are  as  manifold  in  their 
forms  as  are  the  obsessions  of  doubt  or  fear,  and  vary 
in  their  importance  and  severity  from  the  simple  easily 
rejected  suggestion  to  say  or  do  something  outre  or 
wrong  to  the  most  inconvenient  or  dangerous  impulses 
to  serious  crimes,  such  as  assaults,  arson,  suicide,  or 
homicide.  A  conscientious  individual  may  suffer  in- 
tense distress  by  the  persistent  besetting  ideas  of  blas- 
phemy or  other  improper  language;  the  sight  of  a 
weapon  may  suggest  its  use,  and  even  cause  the  com- 
mission of  crime.  The  idea  of  the  act  may  be  con- 
stantly present  for  a  long  time  with  the  individual  or 
may  come  upon  his  consciousness  suddenly,  and  some- 
times without  any  cognizable  external  suggestion  or 
cause.  More  often,  however,  these  sudden  besetments 
of  the  will  are  suggested  by  some  association  with 
objects  or  in  time  or  place.     The  fact  that  a  suicide 


MORBID    IMPULSE.  397 

has  been  committed  in  a  certain  place  and  in  a  spe- 
cial way  has  led  to  its  photographic  repetition  by  one 
of  these  neurasthenics,  and  we  have  known  an  in- 
dividual otherwise  apparently  sane  to  whom  the  sight 
of  a  sharp  ax  or  knife  has  been  more  than  once  the 
occasion  of  an  attempt  at  homicide.  It  is  not  solely 
in  degenerates  that  these  obsessions  are  dangerous; 
they  may  be  equally  so  in  simple  neurasthenics,  a  fact 
the  forensic  importance  of  which  has  not  been  so  fully 
recognized  as  it  ought  to  be. 

Besides  these  more  or  less  fully  developed  impulsions, 
we  have  the  simpler  type  of  purely  intellectual  obses- 
sion without  impulse  to  action,  the  imperative  con- 
ceptions or  fixed  ideas  of  authors.  Here  the  subject  is 
troubled  with  only  a  pervading  thought,  a  notion  or 
even  a  feeling  of  which  he  finds  it  difficult  or  impossible 
to  rid  himself.  It  may  be  a  word  or  a  rhyme,  like 
Mark  Twain's  "Punch  brothers,  punch,  punch  with 
care,  punch  in  the  presence  of  the  passenjare";  or  it 
may  be  a  more  elaborate  conception — an  anticipation 
of  evil,  for  example.  Many  so-called  presentiments  are 
merely  such  neurasthenic  conceptions. 

Apparently  different,  but  really  closely  related,  and 
belonging  to  the  same  general  class  of  pathologic  cere- 
brations, are  the  aboulias  or  defects  of  the  will  involv- 
ing acts,  where  the  patient  has  the  desire,  but  not  the 
power,  to  carry  out  the  movement  or  purpose  of  his 
idea.  There  are  as  many  possibilities  in  this  direction 
as  in  morbid  impulse,  but  fewer  instances  and  varieties 
have  been  described.  Regis  mentions  several  types, 
such  as  the  inability  to  rise  from  a  sitting  posture  or 
to  climb  heights,  for  which  he  suggested  the  names 
ananastasia  and  ananabasia;  the  inability  to  dress  one's 
self,  to  write  one's  name,  etc.  There  is  no  essential 
difference  in  all  these  neurasthenic  besetments  or 
obsessions ;  they  all  have  alike  their  origin  in  an  intel- 
lectual conception,  an  idea,  and  they  all  graduate  into 


398  BORDERLAND    AND    EPISODIC    STATES. 

each  other  in  one  way  or  another.  An  obsession  of 
indecision  may  be  based  on  a  morbid  fear,  or  vice  versa ; 
and  an  impulse  and  aboulic  obsession  may  have  essen- 
tially the  same  mental  mechanism — the  idea  of  com- 
pulsion, of  inability  to  act  otherwise  than  in  the  way 
mentally  suggested.  While  all  these  above  mentioned 
may,  and  perhaps  more  generally  do,  occur  in  indi- 
viduals with  a  more  or  less  marked  degenerative  taint, 
it  does  not  follow  that  this  is  always  the  case.  In 
their  most  pronounced  forms  they  are  only  exaggera- 
tions of  the  experiences  of  average  normal  individuals 
under  certain  special  conditions,  and  we  have  seen 
quite  marked  instances  of  the  obsessions  of  indecision 
and  aboulia  in  persons  without  any  known  special 
neurotic  heredity  or  very  prominent  degenerative  stig- 
mata. These  symptoms  of  mental  or  cerebral  neuras- 
thenia are  frequently  and  perhaps  commonly  asso- 
ciated with  numerous  physical  neurasthenic  symptoms 
— headache,  insomnia,  digestive  disturbances,  par- 
esthesias, etc. ;  but  these  need  not  be  more  than  men- 
tioned here.  They  may  exist  only  under  special  con- 
ditions of  nervous  stress  and  only  once  in  a  lifetime, 
and  they  may  be  continuous  while  they  last  or,  as  is 
more  frequently  the  case,  paroxysmal.  They  hardly 
ever  terminate  in  typical  insanity,  but  these  same 
morbid  impulses  and  other  obsessions,  and  especially 
the  former,  may  occur  in  insanity,  hence  the  occasion- 
ally held  opinion  that  this  is  one  of  their  terminations. 
They  really  represent,  according  to  our  present  knowl- 
edge, quite  a  different  pathologic  state.  They  are, 
however,  not  uncommon  in  epileptics  who  are  not 
actually  insane  or  between  the  attacks  of  real  epileptic 
insanity. 

While  the  subjects  of  the  various  neurasthenic  obses- 
sions above  described  need  not  always  be  pronounced 
degenerates,  though  they  probably  often  fall  to  some 
extent  within  the   general  class    of   originally   defec- 


MORBID    IMPULSE.  399 

tive  organizations,  there  are  certain  related  condi- 
tions that  indicate  very  decidedly  a  morbid  consti- 
tution from  the  start,  and  usually  a  very  notable 
neuropathic  heredity.  These  are  the  periodic  mor- 
bid impulses,  and  their  most  familiar  type  is  periodic 
alcoholism  or  dipsomania.  In  this  there  is  often  first 
the  appearance  of  neurasthenic  depression  in  most 
cases  in  one  form  or  another,  most  commonly  head- 
ache, malaise,  restlessness,  insomnia,  etc.,  to  a  greater 
or  less  extent;  and  there  follows  the  craving  for 
stimulants,  and  the  victim  gives  himself  up  absolutely 
to  the  gratification  of  this  desire.  If  the  ordinary 
alcoholic  stimulants  are  not  available,  anything  in  that 
line  will  be  taken ;  there  is  none  of  the  ordinary  drinker's 
fastidiousness,  anything  strongly  alcoholic  will  be 
taken  with  avidity.  The  attack  may  last  with  brief 
intermissions  for  many  days  or  weeks,  and  then  it 
passes  off,  leaving  the  sufferer  prostrated  and  usually 
much  depressed  also  mentally  for  a  time.  These  at- 
tacks may  occur  at  regular  periods,  with  intervals  of 
months  and  even  years,  during  which  the  subject  is 
often  a  model  citizen,  or  they  may  be  excited  at  any 
time  by  overwork,  mental  strain,  or  misfortune.  In 
many  cases,  but  not  in  all,  as  said  in  a  recently  pub- 
lished text -book,  there  is  a  direct  heredity  of  alcoholic 
habits.  In  this  disorder  the  desire  for  drink  is  com- 
monly called  an  appetite ;  this  is  hardly  the  best  name, 
as  it  signifies  a  desire  for  drink  for  its  own  sake,  which 
is  hardly  the  case.  The  craving  is  simply  the  symptom 
of  the  neurasthenic  or  neuropathic  craving  which  in 
this  type  takes  the  form  of  a  demand  for  stimulation. 
There  is  no  social  element  in  this  type  of  drunkenness 
and  little  real  or  apparent  pleasure ;  the  victim  indulges 
indifferently  alone  or  in  company.  After  a  varying 
period,  with  perhaps  several  attempted  reforms  and 
relapses,  the  attack  passes  off,  leaving  the  subject 
generally  more  or  less  prostrated  and  penitent.     There 


400  BORDERLAND    AND    EPISODIC    STATES. 

is  by  no  means  always  a  direct  heredity  from  parent  to 
child  in  these  cases;  we  have  seen  it  where  heredity, 
if  it  existed,  must  have  skipped  one  or  two  generations, 
and  occurring  in  an  individual  whose  parents'  habits 
were  unexceptionable,  though  there  was  a  record  of 
intemperance  in  the  remoter  ancestry.  It  is  highly 
probable  that  it  may  originate  in  the  victim  himself, 
sometimes  as  a  sequel  of  disease,  though  such  cases  are 
rare,  and  seldom  satisfactorily  observed. 

Degenerative  periodic  impulse  may  appear  in  other 
forms  than  dipsomania;  one  is  the  tendency  to  vaga- 
bondage noticed  sometimes  in  young  persons  who  are 
periodically  seized  with  the  irresistible  desire  to  go  on 
the  tramp.  The  reason  why  this  is  not  often  observed 
in  older  individuals  is  probably  that  in  advanced  life 
these  cases  degenerate  into  steady  vagabonds  or 
criminals,  or  take  to  some  occupation  that  gratifies 
their  impulses.  A  considerable  number  of  regular  pro- 
fessional long-voyage  sailors  appear  to  be  degenerates 
and  "  ne'er-do-wells,"  and  have  possibly  graduated  out 
of  youthful  periodic  vagabonds.  We  have  known  of 
cases  of  this  periodic  morbid  impulse  taking  the  shape 
of  sexual  perversion  in  some  of  its  most  repulsive 
forms,  and  still  others  have  been  reported. 

Sexual  perversion  itself  is,  at  least  in  some  of  its 
manifestations,  to  be  reckoned  amongst  the  degenera- 
tive borderland  conditions.  It  would  be  absurd  to 
claim  that  it  was  always  such,  for  it  may  be  the  result 
of  vicious  habits  and  be  wilfully  cultivated,  as  is  shown 
in  the  records  and  practices  of  some  peoples  of  former 
times  and  in  some  civilizations  at  present,  the  ancient 
Greeks  and  the  modern  Chinese  being  examples. 
Amongthese  people  these  practiceswere  or  are  common, 
and  not  considered  abnormal.  In  many  cases,  how- 
ever, it  is  clearly  due  to  original  defect;  especially  is 
this  true  of  those  congenital  examples  of  perversion 
where  the  physical  stigmata  are  obvious — in  the  sexual 


MORBID    IMPULSE.  40 1 

misfits,  the  femininely  organized  man,  and  the  mascu- 
line women,  mentally  and  emotionally  as  well  as 
physically ;  and  there  are  still  others  in  which  the  con- 
ditions are  not  so  obvious,  but  the  inverted  sexuality 
is  just  as  abnormally  strong.  The  condition  is  not  an 
acceptable  one  to  the  victim  always  in  these  cases, 
and  suicide  or  actual  insanity  may  be  the  result.  In 
other  forms  of  sexual  perversion  the  manifestations 
may  range  through  a  wide  scale,  from  a  comparatively 
harmless  fetichism  for  articles  pertaining  to  women 
to  the  most  abnormal  practices  and  even  the  most 
atrocious  lust-murder.  It  is  hard  to  estimate  respon- 
sibility in  some  of  these,  but  in  many  of  them  we  must 
recognize  degenerative  taint  and  reckon  them  among 
the  borderland  conditions. 

Periodic  kleptomania  may  also  exist,  and  similar 
homicidal  mania,  in  unquestionable  degenerates, 
though  both  of  these  symptoms  may  be  really  only 
aggravated  neurasthenic  manifestations.  These  and 
many  other  so-called  manias,  such  as  pyromania,  etc., 
are  often  only  symptoms  of  profound  degenerative 
neurasthenias,  and  in  this  class,  as  an  extreme  type, 
may  also  be  reckoned  the  tics  or  convulsive  neuroses, 
the  "jumpers"  of  Canada  and  the  Maine  woods,  the 
myriachit  of  Siberia,  and  other  similar  conditions  noted 
in  various  parts  of  the  world.  All  these  neurasthenic 
symptoms  may  be  imposed  upon  actual  mental  weak- 
ness and  alienation,  and  they  are  not  so  very  infre- 
quently observed  in  patients  who  have  recovered  ' '  with 
defect," — that  is,  with  an  impaired  cerebral  organiza- 
tion,— and,  as  already  said,  in  epileptics. 

The  diagnosis  of  these  states  is  generally  simple,  but 

the   facts   just   mentioned   should   not   be   forgotten. 

Pure  neurasthenias  with  the  intellect  unimpaired,  even 

in  their  extreme  forms,  are  seldom  difficult  to  recognize 

and  to  differentiate  from  the  typical  forms  of  mental 

disease.     There  is,   however,   a  neurasthenic  type  of 
26 


402  BORDERLAND    AND    EPISODIC    STATES. 

melancholia  associated  with  fears  and  indecision  that 
may  be  almost  considered  as  a  variety  of  the  genuine 
form,  so  far  as  its  more  obvious  manifestations  are  con- 
cerned. These  patients,  however,  are  less  self-accusa- 
tory, less  positive  in  their  self-condemnation ;  they  may 
worry  over  the  unpardonable  sins  they  fear  they  have 
committed,  but  are  not  so  convinced  of  the  fact  as  is 
the  case  with  the  genuine  melancholiac,  and  they  do 
not  have  the  continuous  distress  of  the  latter;  they 
strive  against  their  feelings,  their  ideas  do  not  have  the 
character  of  actual  delusions,  and  the  symptoms  of 
refusal  of  food  and  wilful  suicidal  intention  and  desire 
to  die  are  not  characteristic.  There  are  undoubtedly 
many  cases,  however,  that  have  been  classed  as  melan- 
choliacs,  and  if  there  is  any  type  of  true  insanity  that 
their  condition  may  most  readily  pass  into,  it  is  likely 
to  be  this.  Certain  cases  of  incipient  paresis  may  also 
cause  confusion  for  a  time,  especially  the  depressed  and 
hypochondriacal  cases  and  those  in  whom  a  klepto- 
mania is  one  of  the  earliest  symptoms.  Sooner  or 
later,  if  not  at  once,  however,  the  characteristic 
physical  and  mental  symptoms  of  paresis  will  remove 
all  doubts  as  to  the  true  nature  of  the  case. 

When  marked  degenerative  stigmata  exist,  they  will 
aid  in  the  diagnosis  to  some  extent,  but  they  are  also 
equally  liable  to  be  present  in  many  other  conditions, 
such  as  hysteria,  imbecility,  original  paranoia,  etc., 
which  may  possibly  in  some  cases  be  complicated  with 
obsessions.  Hysteria  itself  is  a  sort  of  borderland,  but 
it  has  its  special  stigmata  and  characteristics.  The 
so-called  traumatic  neuroses  are  often  mentioned  in 
this  connection,  but  are  best  treated  of  in  special  works 
on  neurasthenia.  There  is  an  occasionally  litigious 
psychosis  connected  with  railroad  traumatism  that  is 
a  genuine  mental  aberration  in  degenerative  indi- 
viduals. In  kleptomania  and  sexual  perversions  it 
may  also  be  difficult  to  exclude  criminality,  and  in 


MORBID    IMPULSE.  403 

many  other  cases  the  diagnosis  of  neurasthenic  obses- 
sional conditions  may  have  a  forensic  importance,  as 
crimes  may  be  committed  in  them  and  the  question 
of  criminal  responsibility  arise.  In  non-degenerative 
cases  or  those  where  the  physical  stigmata  are  few  it 
may  be  difficult  to  establish  irresponsibility,  but  it  is 
well  to  keep  in  mind  the  fact  that  it  may  exist.  The 
whole  history  and  all  the  facts  of  the  case  require  to  be 
learned  and  studied  in  such  cases  with  especial  care. 

The  prognosis  of  neurasthenic  obsessions  and  of  all 
the  borderland  states  we  have  been  considering  depends 
in  each  case  on  the  amount  of  original  defect.  No  one 
would  say  that  the  slight  obsessions  experienced  by 
nearly  every  individual  have  any  dangerous  significance, 
and  yet  in  conditions  of  ill  health  or  with  other  nerve- 
exhausting  factors  they  may  be  greatly  intensified  even 
in  the  normally  constituted.  There  are  many  indi- 
viduals who  cannot  trust  themselves  to  look  down  from 
a  height  and  yet  who  are  in  other  respects  perfectly 
sound  and  sane.  Among  such  individuals  may  be 
reckoned,  on  their  own  testimony,  Verga,  the  dis- 
tinguished Italian  alienist,  and  Beard,  the  first  to  fully 
describe  the  symptoms  of  neurasthenia.  We  have 
seen  very  striking  instances  of  obsessions  of  indecision 
and  of  aboulias  where  the  symptoms  disappeared  com- 
pletely and,  so  far  as  observed,  permanently.  In 
probably  the  majority  of  cases,  however,  there  is  an 
original  nervous  weakness,  and  on  the  amount  of  this 
defect  the  prognosis  depends.  With  a  very  marked 
degenerative  taint  it  is  bad  as  to  recovery,  and  the 
condition  may  even  pass  finally  into  some  form  of 
insanity — true  melancholia  or  some  phase  of  paranoic 
delusion. 

The  treatment  of  these  conditions  is  that  of  neuras- 
thenia, and  sometimes  will  simply  tax  the  skill  and 
tact  of  the  physician.  Change  of  scene  or  occupation 
in  some  cases  will  be  sufficient,  but  travel  is  not  often 


404  BORDERLAND    AXD    EPISODIC    STATES. 

advisable.  Rest,  eliminants,  tonics,  such  as  iron, 
strychnin,  etc,  and  in  some  cases  sedatives,  like  the 
bromids,  cautiously  used,  are  all  of  sendee  in  appro- 
priate cases.  Some  patients  react  well  to  cold  morn- 
ing sponge  tub-baths,  others  are  better  for  warm 
baths  at  night.  General  faradization,  and  static  elec- 
tricity in  some  of  the  forms  of  its  application,  have 
been  highly  recommended  by  some  and  may  some- 
times be  serviceable.  Hypnotism,  though  it  has  its 
advocates,  is  not  to  be  generally  advised;  it  is  of 
dubious  advantage  and  may  do  harm.  One  or  two 
German  authors  have  made  much  of  it,  often  in  an 
objectionable  way,  in  the  treatment  of  sexual  perver- 
sion, but  Ave  cannot  indorse  their  methods.  In  very 
degenerate  cases  a  cure  is  not  to  be  looked  for ;  all  that 
can  be  expected  is  temporary  relief  or  palliation.  In 
a  certain  class  of  neurasthenic  cases  isolation,  with 
special  feeding,  massage,  etc.,  the  Weir  Mitchell  rest 
cure,  may  be  advisable.  One  thing  must  be  espe- 
cially remembered  in  these  cases :  that  every  fact  bear- 
ing on  the  condition,  every  variation  in  general  health, 
every  possible  collateral  or  direct  cause,  should  be 
searched  for  and  studied  for  therapeutic  indications. 


CHAPTER  XXII. 

TERMINAL  DEMENTIA. 

The  great  mass  of  the  inmates  of  our  asylums  are 
cases  of  terminal  stages  of  mental  disease.  We  have 
already  noticed  in  connection  with  the  different  forms 
of  insanity  the  general  symptoms  of  the  secondary 
conditions  that  follow  them.  While  it  is  often  the 
case  that  the  original  condition  implants  its  type  to  a 
greater  or  less  extent  upon  the  terminal  condition,  this 
is  not  by  any  means  the  universal  rule.  All  forms  of 
insanity  of  many  years'  duration,  with  the  exception 
possibly  of  certain  types  of  delusional  derangement, 
fall  under  the  general  head  of  terminal  dementia. 
The  impaired  mental  action  or  dementia  is  charac- 
teristic of  them  all  in  varying  degrees.  In  the  very 
large  proportion  of  cases  it  is  the  one  prominent  feature, 
and  varies  in  its  degree  from  a  mild  general  defect  to  a 
completely  vegetative  condition,  where  the  patient 
can  only  follow  a  certain  simple  routine  requiring  the 
least  possible  degree  of  intellection.  In  the  milder 
form  the  mental  action,  though  limited,  is  sufficient  to 
make  the  patient  a  useful  member  of  the  society  in 
which  he  finds  himself  if  he  is  only  subjected  to  the 
proper  control  and  to  judicious  general  management. 
These  patients  do  well  in  asylums,  and  can  do  much 
to  make  themselves  useful;  outside  of  such  insti- 
tutions they  are,  as  a  rule,  incapable  of  taking  care 
of  themselves.  Their  condition  is,  in  fact,  a  more 
advanced  degree  of  what  we  have  already  described  as 
recovery  with  defect.  Sometimes  they  have  a  certain 
tendency  to  excitement,   and  are  usually  classed  as 

405 


406  TERMINAL    DEMENTIA. 

chronic  maniacs.  In  other  cases  depression  is  the 
ruling  feature,  and  they  are  usually  called  chronic 
melancholiacs.  Delusions  may  be  present  and  very 
marked,  likewise  hallucinations  and  illusions,  and  some 
of  these  cases  fall  under  what  is  called  secondary  para- 
noia ;  and  in  still  other  cases  mental  confusion  is  marked. 
In  fact,  the  symptoms  are  infinitely  varied,  so  that  all 
of  these  types  and  some  others  may  be  counted  in  the 
permanent  population  of  any  large  institution.  The 
bodily  health  in  these  cases  may  be  reasonably  good; 
they  are  able  to  work  and  often  are  extremely  willing 
and  useful;  others,  again,  are  absolutely  helpless,  and 
their  general  condition  requires  the  constant  attention 
of  the  physician,  not  so  much  to  treat  actual  illness 
as  to  oversee  and  prevent  a  general,  more  rapid  decay 
that  would  follow  from  their  lack  of  attention  to  all 
the  ordinary  rules  of  healthful  living.  As  a  rule, 
the  chances  of  life  of  these  patients  are  far  less  than 
those  of  the  average  normal  individual.  They  break 
down  readily  in  disease  and  are  especially  subject  to 
accidental  ailments,  lung  trouble,  etc.  The  average 
mortality  of  an  asylum  which  is  made  up  of  this  class 
is  therefore  higher  than  that  of  communities  in  any 
condition  except  the  [most  unsanitary.  In  a  well- 
regulated  institution  the  death-rate  can  not  well  be 
kept  under  6  or  7  %,  and  while  this  higher  rate  is  largely 
due  to  deaths  in  acute  insanity,  these  chronic  insane 
furnish  far  more  than  their  share  as  estimated  by  the 
usual  ratio  of  deaths  in  the  general  community. 
Outside  of  asylums  and  poorhouses  these  chronic  cases 
are  sometimes  found,  and  with  kindly  and  judicious 
friends  they  manage  to  live  a  comparatively  comfort- 
able existence.  These  cases,  however,  are  exceptional, 
but  the  facts  of  family  care  of  the  insane  as  shown  in 
Belgian  and  Scotch  communities  demonstrate  how 
practicable  this  method  of  controlling  them  may  be 
found.     It  has,   however,   its  disadvantages,   and  re- 


a 


FAMILY   CARE.  407 

quires  to  be  carried  out  under  the  best  conditions  in  a 
stable  community  where  the  traditions  and  customs 
have  been  adapted  to  it  from  generation  to  generation. 
It  also  requires  a  thorough  and  conscientious  medical 
oversight.  Violent  cases  of  this  type,  and  there  are 
many  such,  can  be  properly  cared  for  only  in  an 
asylum,  though  there  are  many  that  surfer  miserably 
in  poorhouses  and  jails. 


CHAPTER  XXIII. 

ON  THE  EXAMINATION  OF  PERSONS 
SUPPOSED  TO  BE  INSANE. 

The  insane  may  be  divided  into  three  classes :  one  so 
manifestly  insane  that  any  layman  can  readily  make 
the  diagnosis ;  another,  in  which  a  physician  with  some 
knowledge  of  insanity  will  easily  make  a  diagnosis; 
and  the  third  class,  in  which  all  the  skill  of  the  medical 
expert  will  be  required  to  reach  a  proper  conclusion. 

The  Method  of  Examination. — This  examination  will 
be  to  determine  whether  or  not  insanity  exists,  what 
will  be  the  duration  and  termination  of  the  attack,  and, 
as  nearly  as  possible,  the  time  when  the  attack  began. 
Conclusions  will  be  reached  in  these  several  instances, 
first,  from  relatives  and  attendants ;  second,  by  an  in- 
spection of  the  patient  and  his  residence  to  deter- 
mine any  sign  of  insanity  in  bodily  stigmata,  in  de- 
portment, in  dress,  in  environment;  third,  by  con- 
versation with  the  patient,  so  as  to  ascertain  the  condi- 
tion of  his  intellect,  emotions,  and  volition;  and,  fourth, 
by  an  examination  of  all  the  organs  of  the  body  that 
are  accessible. 

First,  the  previous  history  of  the  patient.  Care 
must  be  exercised  here  in  properly  estimating  state- 
ments made  by  the  friends;  they  may  be  desirous  of 
establishing  the  insanity  and  exaggerating,  and  indeed 
falsifying,  the  record ;  or  they  may  be  equally  anxious 
to  prove  his  sanity,  and  will  misrepresent  in  the  other 
direction.  The  medical  man,  to  be  a  success  in  his 
investigation,  must  possess  a  logical  mind,  be  able  to 
analyze  evidence,  and  cull  out  that  which  is  defective 
and  untrustworthy.     A  husband  may  want  to  get  rid 

408 


THE    METHOD    OF    EXAMINATION.  409 

of  his  wife,  with  whom  he  does  not  live  happily,  or  the 
respectable  family  may  desire  to  get  rid  of  a  scape- 
grace son,  or  a  crime  may  have  been  committed  and 
no  sufficient  plea  in  defense  be  found.  It  therefore 
behooves  the  physician  making  this  investigation  to  be 
vigilant.  In  making  the  examination  the  hereditary 
predisposition  should  be  inquired  into,  and  it  should 
be  remembered  that  nervous  diseases  undergo  trans- 
mutation in  transmission,  and  that  hysteria,  chorea, 
neuralgia,  alcoholism,  tuberculosis,  etc.,  may  be  the 
hereditary  basis.  Inquiries  should  be  made  as  to  the 
patient's  previous  health  from  infancy  up,  concern- 
ing history  of  convulsions,  chorea,  rachitis,  or  febrile 
diseases  in  childhood ;  character  and  temperament  in 
childhood ;  condition  at  the  developmental  period ;  con- 
dition during  adolescence ;  sexual  relations,  masturba- 
tion, excessive  intercourse  in  marriage  or  illicitly,  vene- 
real diseases ;  we  should  inquire  about  injuries  to  head, 
delirium,  delirium  tremens,  intemperance  in  use  of 
drugs  (opium,  chloral,  cocain,  etc.),  physical  condition, 
habits,  such  as  exercise,  history  of  intellectual  strain,  of 
anxiety,  of  grief  or  disappointment,  as  to  state  of  the 
affections  and  religious  convictions ;  history  of  present 
attack  and  its  probable  etiology. 

Gaining  access  to  the  patient  is  often  difficult,  and 
requires  sometimes  much  talk  and  judgment  on  the 
part  of  the  physician.  Insane  patients  are  often  very 
suspicious,  and  will  refuse  admission  to  medical  men; 
under  these  circumstances  some  medical  men  resort  to 
a  stratagem ;  they  deny  that  they  are  physicians,  and 
approach  the  patient  in  some  less  distasteful  way. 
This  we  are  sure  is  a  mistake.  Honesty  should  be  the 
rule  of  practice.  The  physician  who  entered  the 
presence  of  the  religious  lunatic  as  a  clergyman,  and 
was  asked  by  the  patient  to  pray  with  him,  being  out 
of  practice  in  prayer,  now  thinks  that  dissimulation 
should  not  be  practised.     The  resourceful  man  will 


4IO  EXAMINATION    OF    SUPPOSEDLY    INSANE. 

overcome  the  obstacles  and  get  access  to  the  patient. 
He  will  then  determine  his  general  nutrition;  consider 
the  circulation,  temperature,  stigmata  of  degeneracy; 
condition  of  heart,  lungs,  abdomen,  and  genito-urinary 
system;  reflexes,  motor  and  sensory;  condition  of 
speech,  whether  there  is  stammering,  paretic  scanning, 
verbigeration,  aphasia,  agraphia,  and  apraxia.  He 
will  ascertain  about  sleep;  study  his  facial  expression 
and  gesticulation;  the  appearance  of  the  apartment. 
He  will  carefully  consider  the  psychic  condition,  his 
mode  of  speech,  his  conduct,  whether  he  has  illusions, 
hallucinations,  or  delusions;  the  condition  of  his  emo- 
tions, as  to  his  being  depressed,  excited,  exalted,  irrit- 
able, apathetic ;  his  power  of  attention,  memory, 
judgment. 

While  no  absolute  or  universally  applicable  rules  can 
be  laid  down,  it  is  well,  in  many  doubtful  cases  at  least, 
to  let  the  subject  know  at  once  what  is  the  object  of  the 
investigation;  that  is,  to  state  to  him  that  his  health, 
both  mental  and  physical,  has  been  the  subject  of  sus- 
picion and  that  a  thorough  study  of  his  case  is  desired 
for  his  sake  and  that  of  others.  It  may  put  him  on  his 
guard  to  some  extent,  but  if  he  is  really  insane  he  will 
be  apt  to  betray  it  to  a  careful  examiner.  If  without 
saying  anything  to  excite  opposition  one  can  so  treat 
the  individual  as  a  patient  that  one  can  obtain  his  co- 
operation in  the  study  of  his  case,  so  much  the  better. 
Most  insane  are  aware  that  there  is  something  wrong 
with  them  even  if  they  do  not  wish  to  admit  it,  and 
this  is  especially  true  of  those  cases  where  reasoning 
capacity  is  retained  and  the  diagnosis  is  dubious. 
Perfect  frankness  and  sympathy  with  such  sometimes 
works  admirably;  we  have  been  able  sometimes  to 
induce  them  to  voluntarily  go  to  an  institution  for 
treatment,  in  spite  of  the  presence  of  extreme  suspicion 
leading  to  dangerous  acts.  Every  case,  however,  is 
more  or  less  a  law  to  itself,  and  the  judgment  and  tact 


THE    METHOD    OF    EXAMINATION.  4II 

of  the  examining  physician  will  be  called  upon  to  the 
fullest  extent. 

One  advantage  of  the  thorough  physical  examination 
is  that  it  puts  the  insane  or  suspectedly  insane  in  the 
position  of  a  patient  from  bodily  disease  which  he  may 
or  may  not  himself  suspect,  and  often  to  some  extent 
disarms  his  suspicions,  which  would  be  aroused  by  any 
direct  questions  bearing  on  his  mental  state. 

Letters  and  handwriting  give  much  valuable  informa- 
tion. Insanity  is  sometimes  only  shown  in  writings; 
people  are  often  off  their  guard  in  letter-writing.  It 
will  be  especially  valuable  to  compare  letters  of  to-day 
with  those  written  before  the  attack  began;  not  only 
is  the  composition  of  the  letter  to  be  considered,  but 
the  penmanship,  and  this  should  be  compared  with 
that  months  before.  There  are  sources  of  errors  that 
must  be  borne  in  mind,  such  as  the  simulation  of  in- 
sanity by  the  insane  and  the  concealment  of  delusion 
by  the  insane.  Insane  persons  may  simulate  just 
as  sane  people  may,  and  they  may  simulate  a  form  of 
insanity  different  from  that  which  they  possess.  Occa- 
sionally the  general  practitioner  may  mistake  a  delirium 
due  to  some  visceral  disease  for  an  insanity.  The 
simulated  insanity  by  sane  criminals  will  require  pro- 
longed and  repeated  examination  often  to  detect  it. 
The  forms  usually  simulated  are  acute  mania,  dementia, 
and  melancholia  with  stupor,  or  acute  confusional  in- 
sanity and  epileptic  insanity.  The  physiognomy,  the 
bodily  temperature,  the  condition  of  the  vasomotor 
system,  the  sleep,  are  all  exceedingly  important  in  this 
differentiation.  The  simulator  usually  much  overacts 
his  part,  constantly  seeks  to  give  evidence  of  his 
insanity,  while  the  lunatic  tries  to  conceal  it. 

It  is  worth  while  here  to  state  that  extreme  caution 
should  be  used  in  doubtful  cases  and  the  examiner 
should  be  able  to  give  good  reasons  for  his  belief  in  the 
insanity.     There  should  be  no  mistake  in  diagnosis,  no 


412  EXAMINATION    OF    SUPPOSEDLY    INSANE. 

overpositiveness  on  insufficient  data.  Where  the  com- 
mitment for  insanity  is  a  judicial  proceeding  the 
medical  witness  is  in  a  measure  protected — absolutely 
in  some  States — from  vindictive  prosecution,  but 
where  it  is  made  on  a  medical  certificate  the  maker  is 
sometimes  put  to  serious  inconvenience.  This  is  as 
likely  to  happen  in  cases  of  some  really  though  not 
obviously  insane  as  with  those  where  there  has  been  an 
actual  mistake ;  the  most  troublesome  individuals  of  all 
are  certain  litigious  paranoiacs  or  degenerates  who  can 
make  themselves  appear  to  the  average  person  as  sane. 
Courts  and  juries  are  apt  also  to  be  prejudiced  against 
anything  that  they  think  has  interfered  with  the  liberty 
or  rights  of  the  citizen,  and  do  not  always  do  justice  for 
this  reason.  These  facts  should  be  borne  in  mind,  and 
whoever  certifies  to  the  insanity  in  a  dubious  case 
should  be  certain  of  his  position.  It  is  not  advisable, 
unless  one  has  had  much  experience  with  the  less 
obvious  symptoms  of  derangement  as  shown  by  these 
less  pronounced  types,  to  pose  as  an  expert  or  venture 
to  give  decided  opinions.  Even  experienced  and 
skilled  alienists  are  at  times  at  a  loss  to  detect  satis- 
factory proofs  of  mental  disease  in  a  patient  in  whom 
they  know  it  exists  by  signs  they  cannot  well  describe 
or  define. 

The  details  of  the  psychologic  examination  are  best 
suggested  by  a  study  of  the  descriptions  of  the  various 
types  of  insanity,  and  are  therefore  omitted  here. 


CHAPTER  XXIV. 

THE  ETHICS  OF  INSANITY. 

There  are  in  the  practice  of  almost  every  general 
practitioner  a  number  of  questions  which  arise  relating 
to  insanity  that  may  be  puzzling  and  at  times  severely 
tax  his  judgment;  the  family  physician  especially  is 
liable  to  be  questioned  in  regard  to  matters  of  heredity 
or  of  the  policy  as  to  marriage,  divorce,  the  sequestra- 
tion of  relatives  or  individuals,  etc.,  and  an  answer  may 
at  times  be  difficult  to  give.  First  of  all,  is  the  question 
of  heredity :  one  of  the  most  common  that  the  physi- 
cian is  liable  to  be  asked  is  concerning  the  propriety  of 
marriage  or  of  engaging  in  projects  or  in  business  where 
a  family  history  of  insanity  or  supposed  heredity  exists. 
There  are  many  conscientious  individuals  who  would 
forego  marriage  and  domestic  happiness  for  fear  of 
transmitting  to  offspring  their  hereditary  defects. 
And  there  are  very  many,  less  conscientious,  who 
need  to  be  advised.  Advising  them  is  often  a  thank- 
less task,  and  yet  the  physician  may  be  consulted  by 
relatives  or  others  interested  in  regard  to  their  conduct. 
It  is  safe  to  say  that  insanity  occurring  in  an  individual 
is  liable  to  leave  its  scar  on  his  mental  make-up,  though 
this  may  be  so  insignificant  as  to  be  deprived  of  any 
practical  importance  as  far  as  he  himself  is  concerned. 
When  we  consider,  however,  how  great  a  part  pre- 
disposition plays  in  the  etiology  of  mental  disease,  the 
former  attack  of  insanity  is  a  matter  for  serious  con- 
sideration, no  matter  how  slight  a  trace  it  may  have 
left.  Moreover,  a  person  may  himself  not  have  been 
insane,  but  the  existence  of  insanity  in  other  members 

413 


414  THE    ETHICS    OF    INSANITY. 

of  his  family,  or  especially  in  his  immediate  ancestors, 
may  raise  the  question,  either  in  his  own  mind  or  in 
the  minds  of  others.  A  recovery  from  insanity  is 
practically  complete  in  a  certain  proportion  of  cases. 
It  is  a  disease,  however,  as  compared  with  others,  the 
least  self -protective,  and  the  person  who  has  once 
gone  through  an  attack  of  pronounced  mental  disorder 
is  the  less  immune  to  future  attacks  for  that  reason. 
In  a  certain  proportion  of  cases  where  the  recovery  is 
apparently  complete  there  yet  remains  a  certain  degree 
of  defect,  unrecognizable  by  the  general  public,  but 
more  or  less  apparent  to  the  individual  himself,  and 
sometimes  to  his  nearest  relatives  and  associates.  In 
a  very  considerable  proportion  of  cases  recovery  is 
never  complete,  and  there  is  a  readily  recognizable 
mental  defect,  though  not  sufficient  to  require  the 
individual's  restraint  or  incapacitating  him  for  the 
ordinary  occupation  and  business  of  life.  Such  persons 
mingle  with  the  world,  and  are  looked  upon  as  to  a 
certain  extent  cranks,  or  as  flighty,  eccentric,  or 
peculiar.  In  far  the  greater  proportion  of  cases  re- 
covery never  occurs;  the  degenerated  condition  is  too 
well  established  and  inbred  in  their  constitution  for 
them  ever  to  be  restored  to  their  former  condition  in 
society.  It  would  be  saying  a  great  deal  to  lay  down 
the  rule  that  no  person  who  has  ever  been  insane  should 
marry,  and  yet  it  would  be  on  the  safe  side  if  such  a 
rule  could  be  adopted.  It  is  not  the  decidedly  cranky 
ex-patient  who  is  likely  to  ask  advice,  and  there  are 
many  unfortunate  unions  of  such  individuals.  If 
advice  is  asked  of  the  family  physician  as  to  projected 
marriage  of  one  of  his  clients  to  such  an  individual, 
it  would  be  his  duty  to  point  out  the  possibilities  of 
evil,  and  there  his  duty  would  end.  Society  has  not 
reached  a  point  where  the  advice  given  in  medical 
journals  sometimes,  to  asexualize  the  unrecovered  in- 
sane or  those  who  have  recovered  with  pronounced 


MARRIAGE,    ETC.  415 

defect,  will  be  received  with  favor.  Nevertheless  it 
might  be  a  policy  worthy  of  adoption,  but  its  realiza- 
tion lies  in  the  future.  We  may  lay  it  down  as  a 
safe  rule  to  discourage  all  marriages  of  individuals 
who  have  gone  through  an  attack  of  insanity  arising 
from  apparently  insufficient  cause  or  where  a  strong 
predisposition  or  degenerative  defects  are  known 
to  exist.  It  is  possible  for  a  temporary  delirious 
attack  to  occur,  or  a  mild  confusional  insanity  fol- 
lowing exhaustion  or  diseases  or  exposures  to  intense 
toxic  conditions,  and  yet  not  indicate  any  serious 
mental  depreciation  after  recovery.  We  should  regard 
these  cases  as  excepted  to  a  certain  extent  from  the 
general  rule  of  the  impolicy  of  marriage  of  the  victims 
of  mental  disease.  Still,  it  would  be  safer  if  they,  too, 
could  avoid  offspring  in  a  legitimate  way.  The  celibate 
life  itself  is  to  a  certain  extent  unfavorable  to  mental 
health  under  certain  possible  conditions,  and  it  might 
possibly  be  better  for  the  individuals  in  these  cases  to 
marry;  but  the  possibility  of  transmission  of  a  pre- 
disposition or  mental  weakness  to  children  is  the 
matter  to  be  considered. 

With  regard  to  ancestral  insanity  as  unfitting  a 
person  for  married  life,  many  things  are  to  be  considered 
— the  form  of  insanity  that  has  appeared  in  the  family 
and  the  date  of  its  occurrence  in  relation  to  the  birth 
of  the  individual  in  whose  interest  advice  is  asked.  The 
whole  family  history  as  regards  nervous  and  other  dis- 
eases, questions  of  consanguinity  of  parents,  etc.,  all 
must  be  taken  into  consideration.  If  the  parents  had 
been  themselves  victims,  or  even  the  grand-parents; 
if  there  had  been  anything  like  a  succession  of  suicides 
in  the  ancestry,  with  or  without  other  evidence  of 
mental  aberration;  if  the  insanity  that  occurred  had 
been  of  a  pronouncedly  degenerative  type ;  if  it  was  on 
the  maternal  rather  than  on  the  paternal  side;  if  it 


416  THE    ETHICS    OF    INSANITY. 

was  attended  with  collateral  heredity  of  mental  disease ; 
if  there  was  a  history  of  nervous  disorders,  epilepsy, 
alcoholism,  or  even  of  tuberculosis, — all  these  points 
would  enter  into  the  problem,  and  according  as  they 
existed  singly  or  in  combination,  the  answer  must  be 
made,  as  a  rule,  unfavorably.  If,  on  the  other  hand, 
the  attack  was  a  single  one,  following  traumatism  or 
exhaustive  disease  or  acute  infection  or  intoxication; 
if  there  was  no  collateral  heredity  and  no  decidedly 
neurotic  or  insane  family  history;  if  the  insanity 
occurred  late  in  life,  after  the  birth  of  the  patient  and 
from  apparently  adequate  cause, — the  answer  may  be 
different,  and  there  may  possibly  be  no  contraindica- 
tions whatever  to  the  marriage  of  the  descendant  on 
account  of  mental  disease.  Some  forms  of  insanity 
are  decidedly  hereditary,  and  we  may  say,  as  a  rule, 
that  the  more  degenerative  the  type  occurring  in  the 
parent,  the  greater  the  danger  of  defect  and  predisposi- 
tion to  mental  disorder  in  the  offspring. 

We  must  bear  in  mind  what  has  been  already  taught, 
that  there  are  three  principal  elements  in  the  produc- 
tion of  insanity:  Predisposition,  toxic  influences,  and 
mental  strain  or  stress  of  some  kind  or  other.  Without 
the  first,  the  other  two  are  less  liable  to  produce  the 
disease,  and  according  to  the  amount  of  predisposition 
must  the  danger  be  estimated  in  any  particular  case. 
One  of  the  most  formidable  forms  of  mental  disease — 
general  paresis — is,  webelieve,  one  of  the  least  hereditary, 
depending,  as  it  does,  in  the  vast  majority  of,  if  not 
all,  cases  upon  a  specific  infection.  Nevertheless,  the 
occurrence  of  paresis  in  an  ancestor  is  not  to  be  over- 
looked in  considering  the  possibility  of  mental  break- 
down in  descendants.  There  is  a  certain  amount  of 
truth  in  the  idea  maintained  by  Regis  and  other  French 
authorities  of  a  congestive  heredity  in  these  cases,  and 
the  occurrence  of  paresis  itself  indicates  a  certain  weak- 
ness, since  excesses,  mental  strain,  and  syphilis  are  not 


SENILE    INSANITY.  417 

the  cause  of  the  breakdown  in  many  cases  where  all 
three  exist.  It  should  be  remembered,  moreover,  that 
paresis  is  a  disease  of  the  prime  of  life ;  that  its  syphilitic 
antecedents  often  date  back  many  years,  and  unless 
we  can  be  sure  that  the  poison  did  not  exist  in  the 
system  before  the  birth  or  begetting  of  the  offspring, 
we  cannot  certainly  be  assured  that  the  latter  is  abso- 
lutely free  from  the  taint. 

As  a  general  rule  we  may  say  that  ancestral  insanity 
of  any  type  casts  a  cloud  upon  the  title  of  any  indi- 
vidual to  absolute  mental  health  and  freedom  from 
inherited  predisposition  to  mental  disease.  This  may 
be  cleared  up  by  thorough  study  of  the  case  in  certain 
instances,  but,  as  a  rule,  it  exists. 

The  question  as  to  the  continuance  of  sexual  rela- 
tions of  persons  who  have  recovered  from  mental  dis- 
ease may  possibly  be  asked,  and  the  advice  given 
should  be  governed  by  the  rules  laid  down  in  the  pre- 
ceding pages.  In  some  cases  it  may  be  safe;  in  the 
majority  they  had  better  be  dispensed  with.  In  some 
countries  insanity  of  a  certain  duration  specified  by  law 
is  ground  for  a  divorce,  but  not  in  this  country  so  far 
as  we  are  aware  of  its  laws.  There  is  no  ethical  reason 
why  absolute  divorce  should  be  granted ;  marriage  is  a 
contract  for  better  or  for  worse,  but  a  partial  separa- 
tion, a  divorce  a  thoro,  might  be  an  excellent  provision, 
at  least  in  many  cases. 

Senile  insanity  is  not  necessarily  an  evidence  of 
family  taint.  Each  case  must  be  judged  by  itself.  A 
certain  amount  of  mental  decay  is  almost  normal  in 
old  age,  and  the  hardships  and  strain  of  a  long  life  may 
easily  produce  a  condition  of  mental  breakdown  that 
may  sometimes  be  estimated  as  senile  derangement. 
Therefore,  in  taking  account  of  this  factor  full  inquiry 
should  be  made  to  ascertain  just  how  far  degenerative 
predisposition  may  have  entered  into  the  etiology. 
Atheromatous  degeneration  of  the  arteries  is  a  very 
27 


418  THE    ETHICS    OF    INSANITY. 

common  condition  in  advanced  life,  and  with  it  there 
is  more  or  less  derangement  of  the  circulation  of  the 
nerve-centers  that  may  clinically  manifest  itself  in 
the  greater  or  less  degree  of  the  mental  changes  from 
the  normal.  Senility  is  properly  a  relative  term.  The 
saying  that  " a  man  is  as  old  as  his  arteries"  embodies 
a  practical  truth,  and  a  very  early  appearance  of  mental 
decay  in  advanced  age  should  be  looked  out  for  and 
reckoned  with  in  estimating  the  family  history  as 
regards  the  probabilities  of  insanity. 

To  recapitulate :  it  would  be  better  if  no  one  who  had 
passed  through  an  attack  of  insanity  should  venture 
into  matrimony  or  attempt  to  raise  a  family.  Still, 
in  the  milder  or  more  curable  forms  of  mental  disease 
there  are  many  possible  cases  where  the  chances  of 
morbid  heredity  in  this  direction  are  minimal.  It  is 
especially  in  those  types  of  insanity  which  are  based 
on  a  marked  original,  constitutional  defect,  and  are 
what  we  call  degenerative  in  their  type,  that  the  great- 
est danger  exists.  Among  these  we  may  especially 
recognize  acute  mania,  properly  so  called,  in  the 
limited  sense  in  which  the  term  is  used  in  this  work, 
together  with  other  periodic  forms  and  the  delusional 
types  included  under  the  general  head  of  paranoias, 
that  the  peril  is  greatest.  In  purely  acquired  types, 
including  under  this  head  traumatic  insanity,  toxic 
forms,  and  those  due  to  special  and  entirely  adequate 
conditions  of  shock,  overstrain,  etc.,  the  danger  is 
least.  In  paresis,  though  it  may  indicate  a  certain 
predisposition,  this  element  in  its  etiology,  in  spite  of 
the  views  held  by  some  authorities,  such  as  Naecke,  is 
less  prominent  than  in  many  other  forms  of  insanity. 
The  same  considerations  apply  when  estimating  the 
probabilities  in  the  family  history  of  any  person  who 
may  ask  advice  in  regard  to  his  possible  danger  on 
account  of  insane  relatives.  Every  case  must  be 
judged  by  itself,  and  sometimes  even  the  most  formid- 


MEDICAL   SECRECY.  419 

able  form,  such  as  epilepsy,  is  due  to  an  adequate 
cause,  and  occurring  long  after  the  birth  of  children, 
may  have  no  special  significance.  Paranoia,  however, 
and  circular  insanity  and  special  forms  of  suicidal  in- 
sanity or  aberrations,  perhaps  without  any  other  very 
decided  mental  symptoms,  have  a  bad  significance. 

Occasionally  a  physician's  advice  is  asked  in  regard 
to  business  matters,  especially  the  advantages  and  dis- 
advantages of  certain  forms  of  occupation,  the  dangers 
of  special  projects  contemplated,  etc.,  by  individuals 
who  have  some  doubt  as  to  their  mental  endurance ;  in 
such  instances,  every  case  must  be  judged  by  itself.  But, 
to  be  on  the  safe  side,  whatever  advice  is  given  should 
be  carefully  weighed,  and  based  upon  thorough  study 
of  all  probabilities  and  possibilities.  One  would  not 
wish  to  advise  a  person  with  specially  marked  tendency 
to  insanity  to  undertake  business  operations  involving 
special  mental  strain  or  associations  that  could  be 
damaging  by  any  possibility  to  mental  health.  The 
case  is  best  illustrated  by  the  extreme  example  that 
we  would  not  advise  the  son  of  a  drunkard  to  go  into 
the  liquor  business.  The  same  way  it  would  not  be 
well  for  a  person  in  what  might  be  called  delicate 
mental  health  to  undertake  speculative  occupations 
involving  severe  mental  strain  or  suspense;  still,  as 
already  remarked,  every  case  is  more  or  less  a  law  for 
itself,  and  general  rules  cannot  well  be  laid  down. 

A  very  delicate  question  which  may  arise  to  trouble 
the  medical  man  is  what  is  to  be  done  in  regard  to 
certain  cases  of  insanity  recognized  by  him,  but  not 
altogether  apparent  to  the  general  public,  in  which 
dangerous  tendencies  exist.  Here  the  ethical  question 
of  medical  secrecy  may  be  involved.  Facts  coming  to 
the  knowledge  of  the  physician  may  be  of  importance 
to  other  parties.  One  cannot  learn  of  them  in  the 
ordinary  course  of  events.  In  the  extreme  case  when 
danger  is  imminent  to  individuals  or  to  the  general 


420  THE    ETHICS    OF    INSANITY. 

public,  there  ought  to  be  no  question  as  to  the  phy- 
sician's duty,  and  yet  its  execution  [may  subject  him 
to  some  unpleasant  risks.  Not  long  since  an  English 
physician  was  mulcted  in  damages  to  the  amount  of 
$500  for  giving  his  opinion  as  to  the  insanity  of  a  young 
nurse  who  had  the  charge  of  giving  medicines  and  care 
of  the  sick  and  who  was  suffering  from  the  most  evident 
persecutory  delusions.  It  is  true  that  a  higher  court 
reversed  the  finding  of  the  jury,  but  the  physician  was 
nevertheless  subjected  to  expense  and  serious  incon- 
venience for  a  considerable  period.  There  are  many 
dangerously  insane  at  large  whose  condition  may  be 
recognized,  and  yet  it  would  be  very  imprudent,  in  a 
strictly  utilitarian  point  of  view,  to  make  known  or 
publish  their  condition,  and  still  more  to  take  any 
actual  steps  for  their  sequestration.  The  physician, 
therefore,  will  do  well  to  look  at  all  sides  of  the  question 
in  these  cases  and  govern  himself  accordingly.  In 
cases,  however,  of  actual  and  imminent  danger,  as 
already  said,  his  duty  ought  to  be  clear.  The  un- 
fortunate thing  is  that  ignorant  jurors  and  opinionated 
judges  are  liable  to  bring  about  occasional  miscarriages 
of  justice  in  such  instances.  The  public  needs  educating 
as  to  the  true  nature  of  some  of  the  dangerous  insanities 
that  are  too  much  at  large,  and  which  are  only  called  to 
its  attention  in  the  domestic  or  public  tragedies  that  are 
from  time  to  time  occurring. 


NDEX. 


Aboulias,  58.  392 
Acquired  insanities,  152 
Acts,  insanity  of,  313,  331 
Adhesions     of     membranes     of 

brain,  43 
Adolescent  insanity,   291 

diagnosis,  304 

etiology,  292 

symptoms,  293 

treatment,  305 
Age  in  etiology  of  insanity,  26 
Agoraphobia,  395 
Agostini,  140,  143,  147,  154 
Alcoholic  insanity,   207 

chronic,   211 

hallucinations  in,  213 

maniacal  exacerbations 
of,   214 

pathology  of,  217 

prognosis,  217 

suspicious     delusional, 
212 

treatment,  217 
mania,  acute,   210 
paralysis,   214 
pseudoparesis,  214 
Alcoholism  in  etiology,  21,  34 
Alzheimer,  43,  176 
Amentia,  165 
Analgesia,  73 
Ancestral  insanity,   significance 

of,  413 

Andriezen,   142 

Anemia  of  brain,  43 

Anesthesia,  72 

Angina  pectoris  and  epilepsy,  72 

Arachnoid,  thickening  and  opa- 
cities of,  43 

Argyll- Robertson  pupil,  67 

Arteriosclerosis,  43 

Asphyxias,  local,  69 

Association  tracts,  42 

Astrophobia,  395 

Asylum  vs.  home  care,  100 

Atheroma,  43,  256 

Attendants,     qualifications     of, 


104 


Autointoxication  from  digestive 
tract,  34,  117 


Babcock,  127 

Barker,  42 

Baths  for  insomnia,  106 

Beard,  403 

Bedsores,  68 

Bed -treatment,  120 

Berkeley,   127 

Bevan  Lewis,  378 

Blood,  condition  of,  66 

Bones,  fragility  of,  69 

Borderland  states,  94,  390 

Bourneville,  21 

Bowels,  attention  to,  116 

Brain  disease,  organic,  as  cause, 

37 
Bremer,   245 

Bromids  in  treatment,  107 
Bruce,  127 
Business,  etc.,  advice  as  to,  419 


Campbell,  243 
Catalepsy,  73 
Catatonia,  172,  297 

remissions  in,  302 
Cenesthesis,  disorders  of  the,  59 
Chaslin,  153,  169,  183 
Chloral,  107 

insanity,  225 

diagnosis,  225 

treatment,  236 
Chloralamid,   108 
Choreic  insanity,  284 
Circular  insanity,  332 

diagnosis,  339 

etiology,  333 

symptoms,  333 

treatment,  341 
Civil  condition  in  etiology,  27 
Civilization,  influence  of,  24 
Classification,  133,  147 
of  Agostini,  140 
of  Andriezen,  142 


421 


422 


INDEX. 


Classification  of  Dercum,   141 
of  Italian  Congress   (1901), 

141 
of  Kraepelin,  135 
of  Regis,  137 
of  Ziehen,  134 
Classifications,  table  of,  148,  149 
Claustrophobia,  395 
Climacteric  insanity,    288,    290, 

306 
Climate  in  etiology,  28 
Clouston,  35,  303 
Cocain  in  etiology,  36 
Cocainic  insanity,  223 

relapses  in,  224 

treatment,   224 
Cold  pack,  122 
Collapse  delirium,   153,   155 
Comparison     of     patient     with 

former  self,  94 
Confusional  insanity,  153 

course,  etc.,  164 

definition,  253 

diagnosis,  169 

etiology,  155 

maniacal  type,  158 

pathology,  172 

prognosis,  168 

secondary,   183 

stuporous  type,  162 

symptoms,  157 

treatment,   178 
Congress    of    Mental    Medicine, 

International,  144 
Conium,   no 

Consanguinity,  parental,  22 
Constipation,  64 
Contagion  of  insanity,  38 
Contractures,  73 
Cotard,  301 

Course   and  termination   of  in- 
sanity, 77 
Cranial  deformities,  75 
Cranks,  391 
Cremnophobia,   395 
Cretinism,  33,  386 
Critical  periods,  31 

insanities  of,  289 
Cysts,  arachnoid,  43 

Dagonet,  26,  28,  126 
Deception  of  patient,  96,   127 
Definition  of  insanity,  12 
Degenerative  insanities,  314 
Delire  des  negations,  201 
Delirium,  acute,  153,  164 

acute     hallucinatory,     155, 
160 

tremens,  34,  208 


Delusions,  47,  93 
Dementia,  acute,  153 

paranoides,  297 

praecox,  291 

terminal,  405 
Depression,  emotional,  55 

simple,   59 
Dercum,  42,  141 
Dermography,  69 
Destructi  veness ,   124 
Developmental  periods,  31 
Diagnosis,  general,  89 
Dipsomania,  216,  399 
Dirty  habits,  123 
Disappointment  in  love    (etiol- 
ogy), 3° 
Discipline,   129 

Domestic  troubles  (etiology),  29 
Dotto,  67 

Double  consciousness,  61 
Doubting  insanity,  393 
Drug  intoxications  in  insanity, 

34,  206 
Dura,  ossification  of,  43 
Duration  of  insanity,  80 

Ear,  deformities  of,  75 
Edema,  blue,  68 
of  brain,  43 
Education  and  insanity,  25 
Electricity,    122 
Ellis,  H.,  57 

Emotional  disturbances,  55 
Employment,  119 
Epilepsy,  larvated,  266 

parental,  21 
Epileptic  equivalents,   268 
insanity,  260 

bromids  in,  273 

diagnosis,  270 

prognosis,  271 

treatment,  292 

types  of,  265 
Epileptics,  mortality  of,  87 
Esquirol,  19 
Ethics  of  insanity,  413 
Etiology,  general,  18 
Exaltation,  emotional,  56 

of  cenesthesis,  59 
Examination  of  patient,  90,  408 
Exciting  causes,  29 
Excretions,  90 
Exercise,  119 
Exhaustion  as  cause,  37 
Exhaustional  types  of  insanity, 

i52 

Face,  irregularities,  75 
Family  cares,  105 


INDEX. 


423 


Fatigue,  nerve  changes  from,  42 

Feeding,  artificial,   111 

dangers  of,   113,   114 
duration  of,   115 
materials  for,  114 

Fixed  ideas,  93 

Flechsig,  42 

Folie  a  deux,  38 

Folie  du  doute,  393 

Food,  refusal  of,  64,  in,  196 

Galton,  19 

Gastric  functions,  118 

Genitals,  misshapen,   75 

Glia,  proliferation  of,  44 

Gout,  heredity  of,  20 

Great  Britain,  insanity  in,  16 

Griesinger,   14 

Griibelsucht,   393 

Gynecologic  operations,  125,  126 

Hair  and  beard,  anomalies  of, 
76 

Hallucinations,  50,  92 
auditory,   51 
of  smell  and  taste,  54 
tactile,    temperature,    etc., 

55 
visual,  53 

Hammarberg,  378,  386 

Haschisch,  229 

Hebephrenia,  291 

Heredity,  18,  23 

History  of  case,  study  of,  94 

Hobbs,  125 

Hoch,  177 

Hodge,  42,  173 

Holt,  125 

Home  treatment,   100 

cases   suited   for,    102, 

123 
essentials  of,   103 

Homicide,  dangers  of,  197 

Hydrotherapy,    122 

Hyoscin  hydrobromate,  109 

Hyoscyamus ,   no 

Hyperesthesia,  72 

Hypnotics,  107 

Hypnotism,  123 

Hypochondriacal  insanity,  287 

Hypomania,  316,  321 

Hysteria,  parental,  21 
traumatic,   281 

Hysteric  insanity,  275 
diagnosis,  281 
heredity  in,  276,  316 
prognosis     and     treat- 
ment,  282 
types  of,  277 


Identity,  personal,  loss  of,  61 
Idiocy  and  imbecility,  377 

diagnosis     and     prog- 
nosis, 387 
treatment,  388 

acquired,  385 

distinction     of,     from     im- 
becility,  381 

hydrocephalic,  386 

microcephalic,  384 

mongolian,  383 

physical  signs  of,  378 
Idiots,  types  of,  381 
Illinois,  insanity  in,  16 
Illusions,  48 

Immigration  and  insanity,  17 
Impulsions,  58,  93,  390 
Increase  of  insanity,  16,  17 
Insomnia,  61 
Intimidation,  129 
Iodoform  insanity,  226 
Ireland,  Dr.,  388 


Jaws,  irregularities  of,  75 


Kane,  222 

Kidney  disorders,  33 

Kiernan,  156,  303,  390 

Klein,  66 

Kleptomania,  10 1 

Knecht,  41 

Koller,  Jennie,  23 

Kraepelin,  35,  45,  98,  135,  144, 

i47>   i5°.   ^S.   IS4.   !56.  *57. 
172,  186,  254,  297,  315,  316 
Krafft-Ebing,  57 


Lannelongue's  operation,  125 
Lesions  of  insanity,  42,  43 
Lowenstein,  389 
Lugaro,  173 


Mabon,  127 
Macpherson,   373 
McPhail,  127 
Macrocephaly,  75 
Mania,  diagnosis,  325 

etiology,  317 

pathologic  anatomy,  325 

prognosis,  98,  327 

reasoning,    331 

recurrent,  316 

sine  delirio,  323 

symptoms,  318 

treatment,  329 
Mann,  173 


424 


INDEX. 


Marandon  de  Montyel,  183,  184 

Marce,  12,  14 

Marriage  and  insanity,  413 

Massage,  122 

Masturbation,  insanity  of,  292 

Maternal  heredity,  20 

Medical  secrecy,  419 

Melancholia,    185 

attonita,  193 

course  and  termination,  198 

etiology,  186 

hallucinations  in,  192 

opium  in,  205 

pathologic  anatomy,  197 

prognosis,  98,  202 

treatment,  203 
Melancholic  frenzy,  191 
Memory,  disorders  of,  60 
Mendel,  245 

Menstruation,  disorders  of,  65 
Mental  shock,  29 
Mercier,   375 

Metaphysical  mania,  393 
Meyer,  A.,   198 
Meyer,  L. ,  243 
Microcephalic  idiocy,  384 
Microcephaly,   75 
Middlemass,   127,  378 
Mind,  fourfold  divisions  of,  46 
Moeli,   156 
Moll,  57 

Mongolian  idiocy,  383 
Moral  causes,  29 

idiocy,  370 

responsibility  in,   373 

insanity,  369 

prognosis     and     treat- 
ment, 376 

perversion,  56 

treatment,  127,  131 
Morbid  impulse,  58,  396 

periodic,  399 
Morphinism,    219 

prognosis    and    treatment, 
221 
Mortality,  ratio  of,  86 
Mosso,  174,   177 
Motor  symptoms,  73 
Mott,  247 
Mysophobia,   395 
Myxedema,  33 


Nasal  feeding-tube,  use  of,  in 
Neuralgic  symptoms,  72 
Neurons,  contact  of,  42 
Neuroses,  insanities  of  the,  259 
Neurotic  heredity,  20,  21 
New  York,  insanity  in,  16 
Nissl,  177 


Nostalgia,  187 

Nutrition,  disorders  of,  64 


Obsession  propension,  396 
Obsessions,  316,  390,  391 

neurasthenic,  treatment  of, 
403 

of  fear,  395 

of  indecision,  393 
Occupations  as  cause,  28 
Onset  of  insanity,  77 
Opium  as  hypnotic,  109 
Organic  causes,  37 

dementia,  355 

insanity,  355 
Organotherapy,  127 
Othematoma,  67 


Pacchionian  granulations,  43 

Paraldehyd,  108 

Paralysis,  hypochondriacal,  74 

hysteric,  74 
Paralytic  disorders,  74 
Paranoia,  342 

causes  of,  344 

definition,    343 

diagnosis,  364 

hallucinations  in,  345 

litigious,  352 

megalomaniac,  349 

original,  356,  392 

persecutory     delusions     in, 
346 

prognosis,  366 

symptoms  and  stages,  345 

treatment  of,  367 

varieties  of,  351 
Paresis,  74,  238 

age  and  sex  and,  230 

cause  of  death  in,  87 

civilization  and,  231 

conjugal,  232 

convulsive    and   congestive 
attacks  in,  243 

diagnosis,  247 

etiology,  229 

fragility  of  bones  in,  243 

heredity,  231 

juvenile,  232 

occupation  and,   231 

pathology  of,  246 

prognosis,  250 

remissions  in,  245 

speech  disorders,  238 

symptomatology,   236 

syphilis  and,  230 

treatment,  250 

types  of,  241 


INDEX. 


425 


Paretic  dementia,  paresis,   238 

Passage  to  chronic  types,  85 

Paternal  heredity,  23 

Pathology  of  insanity,  40 

Pellagra,  36 

Perspiration,  disorders  of,  65 

Phobias,  316,  390,  395 

Physical  exciting  causes,  30 

Political    conditions    (etiology) , 
28 

Pre-   and   post-epileptic   insani- 
ties, 268 

Precordial  anxiety,   72 
pain,  195 

Prendergast  case,  365 

Prevalence  of  insanity,  12 

Prodromata,  77,  78 

Professions  and  occupation  (eti- 
ology),  28 

Prognosis,  89,  96 

Pulse,  high  tension,  significance 
of,  70 


OuERULANTENWAHNSINN,   352 


Race  and  insanity,  28 
Recovery  from  insanity,  81,  82 

with  defect,  85 
Recurrences,  81 
Recurrent  insanity,  315 
Reflexes,  condition  of,  66 

ocular,  66 
Regis,  13,  14,  15,  136,  137,  393, 

396 
Religious   excitement   as  cause, 

3° 

Remissions,  80 

Reproductive    instinct,    aberra- 
tion of,  57 

Rest-in-bed  treatment,  120 

Restraint  apparatus,  121 

Rohe,   125 


Sachs,  385 

Salivary  secretion,  65 

Scaphocephaly,   75 

Schroeder  van  der  Kolk,  65,  175 

Seclusion.   121 

Secretions,  disorders  of,  65 

Sedatives,  no 

Self-preservation,  instinct  of,  57 

Semi-imbeciles,  379 

Senile  insanity,  306,  417 

and    gross    brain    dis- 
ease, 308,  311 

diagnosis,  312 


Senile  insanity,  treatment,  313 

types  of,  309 
Senn,  N.,  226 
Sensations,  46 

Sensibility,  alterations  of,  72 
Serumtherapy,    127 
Sex  and  insanity,  27 
Sexual  perversion,  95,  40c 

relations,  417 
Simulation  of  insanity,  411 
Skin,  condition  of,  75 
Sleep,  disorders  of,  62 
Somnolence,  62 
Soukhanin,  173 
Spiller,  41 

Spitzka,  13,  14,  18,  42,  153 
Stigmata,  4,  75 
Stomach-tube,  in 
Stupor,    degenerative    type    of, 

F7.1 

Suicide,  degrees  of,   124,  196 

Sulphonal,   108 

Sunstroke,   32 

Surgical  operations  as  cause,  32 

treatment.   125 
Symptomatology,  general,  45 
Syphilis  as  cause,  86 

hereditary,  22 
Syphilitic  insanity,  257 


Tarnowsky,  57 
Teeth,  grinding  of,  73 

irregularities  of,  75 
Temperature  in  insanity,  70 

subnormal,  72 
Terminations  of  insanity,  81 
Thorax,  deformities  of,  75 
Thyroid  treatment,  127 
Tics,   58 
Tonics,   in 
Toxemic     insanities,     prognosis 

in,  97 
Toxic  causes,  33 

insanities,  206 
Transitory  frenzy,  79 
Traumatic  causes,  31 
Treatment,  general,  106 

moral,  127 
Tremor,  73 
Trional,  108 
Trophic  changes,  67 
Tuke,  J.  B.,  177 
Turner,   177,    198 


Urine,  condition  of,  66 
suppression  of,   116 


426  INDEX. 

Verbigeration,  298  Whitwell,  177 

Verga,  403  Will,  disorders  of  the,  57 

Verrucktheit  originare,  315  Wille,   176 

Verwirrheit,  153  Writing  of  the  insane,  94,   391, 

Von  Solder,  176  411 


Waxy  flexibility,  73  Ziehen,  classification  of,  134 


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inson, M.  D.  Handsome  imperial  octavo  volume  of  1014  pages; 
nearly  900  beautiful  colored  and  half-tone  illustrations.  Cloth,  $7.00 
net;   Sheep  or  Half  Morocco,  $8.00  net.     Sold  by  Subscription. 

An  American  Text-Book  of  Pathology. 

Edited  by  Ludvig  Hektoen,  M.  D.,  Professor  of  Pathology  in  Rush 
Medical  College,  Chicago;  and  David  Riesman,  M.  D.,  Demonstrator 
of  Pathologic  Histology  in  the  University  of  Pennsylvania.  Imperial 
octavo,  over  1250  pages,  443  illustrations,  66  in  colors.    By  Subscription. 

An  American  Text-Book  of  Physiology,    second  Edition, 

Revised,  in  Two  Volumes. 

Edited  by  William  H.  Howell,  Ph.  D.,  M.  D.,  Professor  of  Physi- 
ology, Johns  Hopkins  University,  Baltimore,  Md.  Two  royal  octavo 
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An  American  Text- Book  of  Surgery.    Third  Edition. 

Edited  by  William  W.  Keen,  M.  D.,  LL.  D.,  F.  R.  C.  S.  (Hon.) ;  and 
J.  William  White,  M.  D.,  Ph.  D.  Handsome  octavo  volume  of  1230 
pages;  496  wood-cuts  and  37  colored  and  half-tone  plates.  Thoroughly 
revised  and  enlarged,  with  a  section  devoted  to  "The  Use  of  the  Ront- 
gen  Rays  in  Surgery."  Cloth,  $7.00  net;  Sheep  or  Half  Morocco, 
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GET  THE  BEST  THE  NEW  STANDARD 

The  American  Illustrated  Medical  Dictionary. 

Second  Edition,  Revised. 

For  Practitioners  and  Students.  A  Complete  Dictionary  of  the  Terms 
used  in  Medicine,  Surgery,  Dentistry,  Pharmacy,  Chemistry,  and  the 
kindred  branches,  including  much  collateral  information  of  an  encyclo- 
pedic character,  together  with  new  and  elaborate  tables  of  Arteries, 
Muscles,  Nerves,  Veins,  etc.  ;  of  Bacilli,  Bacteria,  Micrococci,  Strepto- 
cocci ;  Eponymic  Tables  of  Diseases,  Operations,  Signs  and  Symptoms, 
Stains,  Tests,  Methods  of  Treatment,  etc.,  etc.  By  W.  A.  Newman 
Dorland,  A.M.,  M.  D.,  Editor  of  the  "American  Pocket  Medical 
I  Dictionary."  Handsome  large  octavo,  nearly  800  pages,  bound  in 
full  flexible  leather.     Price,  $4.50  net;   with  thumb  index,  $5.00  net. 

Gives  a  Maximum  Amount  of   Matter  in   a   Minimum   Space   and   at  the  Lowest 

Possible  Cost. 

This  Edition  contains  all  the  Latest  Words. 

"  I  must  acknowledge  my  astonishment  at  seeing  how  much  he  has  condensed  within 
relatively  small  space.  I  find  nothing  to  criticise,  very  much  to  commend,  and  was  interested 
in  finding  some  of  the  new  words  which  are  not  in  other  recent  dictionaries." — ROSWELL  PARK, 
Professor  of  Principles  and  Practice  of  Surgery  and  Clinical  Surgery,  University  of  Buffalo. 

"  I  congratulateyou  upon  giving  to  the  profession  a  dictionary  so  compact  in  its  structure, 
and  so  replete  with  information  required  by  the  busy  practitioner  and  student.  It  is  a  necessity 
as  well  as  an  informed  companion  to  every  doctor.  It  should  be  upon  the  desk  of  every  prac- 
titioner and  student  of  medicine." — TOHN  B.  MURPHY,  Professor  of  Surgery  and  Clinical 
Surgery,  Northwestern   University  Medical  School,  Chicago. 

The  American  Pocket  Medical  Dictionary.    ThkJ  ™?on' 

Revised. 

Edited  by  W.  A.  Newman  Dorland,  M.  D.,  Assistant  Obstetrician  to 
the  Hospital  of  the  University  of  Pennsylvania ;  Fellow  of  the  Amer- 
ican Academy  of  Medicine.  Containing  the  pronunciation  and  defini- 
tion of  the  principal  words  used  in  medicine  and  kindred  sciences,  with 
64  extensive  tables.  Handsomely  bound  in  flexible  leather,  with  gold 
edges.     Price  $1.00  net;  with  thumb  index,  $1.25  net. 

The  American  Year-Book  of  Medicine  arid  Surgery. 

A  Yearly  Digest  of  Scientific  Progress  and  Authoritative  Opinion  in  all 
branches  of  Medicine  and  Surgery,  drawn  from  journals,  monographs, 
and  text-books  of  the  leading  American  and  Foreign  authors  and  investi- 
gators. Arranged  with  critical  editorial  comments,  by  eminent  Amer- 
ican specialists,  under  the  editorial  charge  of  George  M.  Gould,  M.  D. 
Year-Book  of  1901  in  two  volumes — Vol.  I.  including  General  Medicine; 
Vol.  II. ,  General  Surgery.  Per  volume :  Cloth,  $3.00  net;  Half  Mo- 
rocco, $3.75   net.      Sold  by  Subscription. 

Abbott  on  Transmissible  Diseases,    second  Edition,  Revised. 

The  Hygiene  of  Transmissible  Diseases :  their  Causation,  Modes  of 
Dissemination,  and  Methods  of  Prevention.  By  A.  C.  Abbott,  M.  D., 
Professor  of  Hygiene  and  Bacteriology,  University  of  Pennsylvania. 
Octavo,  351  pages,  with  numerous  illustrations.     Cloth,  $2.50  net. 


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Anders'  Practice  of  Medicine.       Fifth  Revised  Edition. 

A  Text-Book  of  the  Practice  of  Medicine.  By  James  M.  Anders, 
M.  D.,  Ph.  D.,  LL.  D.,  Professor  of  the  Practice  of  Medicine  and  of 
Clinical  Medicine,  Medico-Chirurgical  College,  Philadelphia.  Hand- 
some octavo  volume  of  1292  pages,  fully  illustrated.  Cloth,  $5.50  net; 
Sheep  or  Half  Morocco,  S6.50  net. 

Bastin's  Botany. 

Laboratory  Exercises  in  Botany.  By  Edson  S.  Bastin,  M.  A.,  late 
Professor  of  Materia  Medica  and  Botany,  Philadelphia  College  of 
Pharmacy.     Octavo,  536  pages,  with  87  plates.     Cloth,  $2.00  net. 

Beck  on  Fractures. 

Fractures.  By  Carl  Beck,  M.  D.,  Surgeon  to  St.  Mark's  Hospital  and 
the  New  York  German  Poliklinik,  etc.  With  an  appendix  on  the  Prac- 
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Beck's  Surgical  Asepsis. 

A  Manual  of  Surgical  Asepsis.  By  Carl  Beck,  M.  D.,  Surgeon  to  St. 
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Bergey's  Principles  of  Hygiene. 

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cians, and  Health  Officers.  By  D.  H.  Bergey,  A.M.,  M.  D.,  First 
Assistant,  Laboratory  of  Hygiene,  University  of  Pennsylvania.  Hand- 
some octavo  volume  of  495  pages,  illustrated.     Cloth,  S3- 00  net. 

Boisliniere's    Obstetric   Accidents,   Emergencies,  and 
Operations. 

Obstetric  Accidents,  Emergencies,  and  Operations.  By  L.  Ch.  Bois- 
liniere,  M.  D.,  late  Emeritus  Professor  of  Obstetrics,  St.  Louis  Medical 
College.      381  pages,  handsomely  illustrated.      Cloth,  S2.00  net. 

Bohm,  Davidoff,   and  Huber's  Histology. 

A  Text-Book  of  Human  Histology.  Including  Microscopic  Technic. 
By  Dr.  A.  A.  Bohm  and  Dr.  M.  von  Davidoff,  of  Munich,  and 
G.  Carl  Huber,  M.  D.,  Junior  Professor  of  Anatomy  and  Director  of 
Histological  Laboratory,  University  of  Michigan.  Handsome  octavo 
of  503  pages,  with  351  beautiful  original  illustrations.     Cloth,  $3.50  net. 

Butler's  Materia  Medica,  Therapeutics,  and  Pharma- 
cology.     Third  Edition,  Revised. 

A  Text-Book  of  Materia  Medica,  Therapeutics,  and  Pharmacology. 
By  George  F.  Butler,  Ph.  G.,  M.  D.,  Professor  of  Materia  Medica  and 
of  Clinical  Medicine,  College  of  Physicians  and  Surgeons,  Chicago. 
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Chapin  on  Insanity. 

A  Compendium  of  Insanity.  By  John  B.  Chapin,  M.  D.,  LL.  D., 
Physician-in-Chief,  Pennsylvania  Hospital  for  the  Insane ;  Honorary 
Member  of  the  Medico-Psychological  Society  of  Great  Britain,  of  the 
Society  of  Mental  Medicine  of  Belgium,  etc.  i2mo,  234  pages,  illus- 
trated.    Cloth,  $1.25  net. 

Chapman's   Medical    Jurisprudence  arid  Toxicology. 

Second  Edition,  Revised. 

Medical  Jurisprudence  and  Toxicology.  By  Henry  C.  Chapman, 
M.  D.,  Professor  of  Institutes  of  Medicine  and  Medical  Jurisprudence, 
Jefferson  Medical  College  of  Philadelphia.  254  pages,  with  55  illus- 
trations and  3  full-page  plates  in  colors.     Cloth,  $1.50  net. 

Church  arid  Peterson's  Nervous  arid  Mental  Diseases. 

Third  Edition,  Revised  and  Enlarged. 

Nervous  and  Mental  Diseases.  By  Archibald  Church,  M.  D.,  Pro- 
fessor of  Nervous  and  Mental  Diseases,  and  Head  of  the  Neurological 
Department,  Northwestern  University  Medical  School,  Chicago ;  and 
Frederick  Peterson,  M.  D.,  Chief  of  Clinic,  Nervous  Department, 
College  of  Physicians  and  Surgeons,  New  York.  Handsome  octavo 
volume  of  875  pages,  profusely  illustrated.  Cloth,  $5.00  net;  Sheep  or 
Half  Morocco,  $6.00  net. 

Clarkson's  Histology. 

A  Text-Book  of  Histology,  Descriptive  and  Practical.  By  Arthur 
Clarkson,  M.  B.,  C.  M.  Edin.,  formerly  Demonstrator  of  Physiology 
in  the  Owen's  College,  Manchester;  late  Demonstrator  of  Physiology 
in  Yorkshire  College,  Leeds.  Large  octavo,  554  pages;  22  engravings 
and  174  beautifully  colored  original  illustrations.     Cloth,  $4.00  net. 

Corwin's  Physical  Diagnosis.    Third  Edition,  Revised. 

Essentials  of  Physical  Diagnosis  of  the  Thorax.  By  Arthur  M. 
Corwin,  A.M.,  M.  D.,  Instructor  in  Physical  Diagnosis  in  Rush 
Medical  College,  Chicago.    219  pages,  illustrated.     Cloth,  $1.25  net. 

DaC0Sta's    Surgery.       Third  Edition,  Revised. 

Modern  Surgery,  General  and  Operative.  By  John  Chalmers  Da 
Costa,  M.  D. ,  Professor  of  Principles  of  Surgery  and  Clinical  Surgery, 
Jefferson  Medical  College,  Philadelphia;  Surgeon  to  the  Philadelphia 
Hospital,  etc.  Handsome  octavo  volume  of  1117  pages,  profusely 
illustrated.     Cloth,  $5.00  net;    Sheep  or  Half  Morocco,  $6.00  net. 

Enlarged  by  over  200  Pages,  with  more  than  100  New  Illustrations. 

Davis's  Obstetric  Nursing. 

Obstetric  and  Gynecologic  Nursing.  By  Edward  P.  Davis,  A.  M., 
M.  D.,  Professor  of  Obstetrics,  Jefferson  Medical  College  and  Phila- 
delphia Polyclinic;  Obstetrician  and  Gynecologist,  Philadelphia  Hos- 
pital.     i2mo,  400  pages,  illustrated.      Crushed  Buckram,  $1.75  net. 


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DeSchweinitz  on  Diseases  of  the  Eye.  Third  Edition,  Revised. 

Diseases  of  the  Eye.  A  Handbook  of  Ophthalmic  Practice.  By  G. 
E.  de  Schweinitz,  M.  D.,  Professor  of  Ophthalmology,  Jefferson  Medi- 
cal College,  Philadelphia,  etc.  Handsome  royal  octavo  volume  of  696 
pages;  256  fine  illustrations  and  2  chromo-lithographic  plates.  Cloth, 
$4.00  net;  Sheep  or  Half  Morocco,  $5.00  net. 

Borland's  Dictionaries. 

[See  American  Illustrated  Medical  Dictionary  and  American 
Pocket  Medical  Dictionary  on  page  3.] 

Dorland's    Obstetrics.       Second  Edition,  Revised  and  Greatly  Enlarged. 

Modern  Obstetrics.  By  W.  A.  Newman  Dorland,  M.  D.,  Assistant 
Demonstrator  of  Obstetrics,  University  of  Pennsylvania;  Associate  in 
Gynecology,  Philadelphia  Polyclinic.  Octavo  volume  of  797  pages, 
with  201  illustrations.     Cloth,  $4.00  net. 

Eichhorst's  Practice  of   Medicine. 

A  Text-Book  of  the  Practice  of  Medicine.  By  Dr.  Herman  Eichhorst, 
Professor  of  Special  Pathology  and  Therapeutics  and  Director  of  the 
Medical  Clinic,  University  of  Zurich.  Translated  and  edited  by  Augus- 
tus A.  Eshner,  M.  D.,  Professor  of  Clinical   Medicine,  Philadelphia 

Polyclinic.    Two  octavo  volumes  of  600  pages  each,  over  150  illustrations. 

Prices  per  set:   Cloth,  #6.00  net;  Sheep  or  Half  Morocco,  $7.50  net. 

Friedrich  and  Curtis  on  the  Nose,  Throat,  and  Ear. 

Rhinology,  Laryngology,  and  Otology,  and  Their  Significance  in  Gen- 
eral Medicine.  By  Dr.  E.  P.  Friedrich,  of  Leipzig.  Edited  by  H. 
Holbrook  Curtis,  M.  D.,  Consulting  Surgeon  to  the  New  York  Nose 
and  Throat  Hospital.     Octavo,  348  pages.     Cloth,  $2.50  net. 

Frothingham's  Guide  for  the  Bacteriologist. 

Laboratory  Guide  for  the  Bacteriologist.  By  Langdon  Frothingham, 
M.  D.  V.,  Assistant  in  Bacteriology  and  Veterinary  Science,  Sheffield 
Scientific  School,  Yale  University.     Illustrated.     Cloth,  75  cts.  net. 

Garrigues'  Diseases  of  Women.    Third  Edition,  Revised. 

Diseases  of  Women.  By  Henry  J.  Garrigues,  A.  M.,  M.  D.,  Gyne- 
cologist to  St.  Mark's  Hospital  and  to  the  German  Dispensary,  New 
York  City.  Octavo,  756  pages,  with  367  engravings  and  colored  plates. 
Cloth,  $4.50  net;  Sheep  or  Half  Morocco,  $5.50  net. 

Gorham's  Bacteriology. 

A  Laboratory  Course  in  Bacteriology.  By  F.  P.  Gorham,  M.  A., 
Assistant  Professor  in  Biology,  Brown  University.  i2mo  volume  of 
192  pages,  97  illustrations.      Cloth,  $1.25  net. 


OF   W.  B.  SAUNDERS   &>    CO. 


Gould  and  Pyle's  Curiosities  of  Medicine. 

Anomalies  and  Curiosities  of  Medicine.  By  George  M.  Gould,  M.  D. 
and  Walter  L.  Pyle,  M.  D.  An  encyclopedic  collection  of  rare  and 
extraordinary  cases  and  of  the  most  striking  instances  of  abnormality  in 
all  branches  of  Medicine  and  Surgery,  derived  from  an  exhaustive 
research  of  medical  literature  from  its  origin  to  the  present  day, 
abstracted,  classified,  annotated,  and  indexed.  Handsome  octavo 
volume  of  968  pages;  295  engravings  and  12  full-page  plates.  Popular 
Edition.      Cloth,  $3.00  net;  Sheep  or  Half  Morocco,  $4.00  net. 

Grafstrom's  Mechano-Therapy. 

A  Text-Book  of  Mechano-Therapy  (Massage  and  Medical  Gymnastics). 
By  Axel  V.  Grafstrom,  B.  Sc,  M.  D.,  late  House  Physician,  City  Hos- 
pital, Blackwell's  Island,  New  York.  i2mo,  139  pages,  illustrated. 
Cloth,  $1.00  net. 

Griffith    On    the    Baby.       Second  Edition,  Revised. 

The  Care  of  the  Baby.  By  J.  P.  Crozer  Griffith,  M.  D.,  Clinical 
Professor  of  Diseases  of  Children,  University  of  Pennsylvania;  Phy- 
sician to  the  Children's  Hospital,  Philadelphia,  etc.  i2mo,  404  pages; 
67  illustrations  and  5  plates.     Cloth,  $1.50  net. 

Griffith's  Weight  Chart. 

Infant's  Weight  Chart.  Designed  by  J.  P.  Crozer  Griffith,  M.  D., 
Clinical  Professor  of  Diseases  of  Children,  University  of  Pennsylvania. 
25  charts  in  each  pad.     Per  pad,   50  cts.  net. 

Hart's  Diet  in  Sickness  and  in  Health. 

Diet  in  Sickness  and  Health.  By  Mrs.  Ernest  Hart,  formerly  Student 
of  the  Faculty  of  Medicine  of  Paris  and  of  the  London  School  of  Medi- 
cine for  Women ;  with  an  Introduction  by  Sir  Henry  Thompson, 
F.  R.  C.  S.,  M.  D.,  London.     220  pages.     Cloth,  $1.50  net. 

Haynes'  Anatomy. 

A  Manual  of  Anatomy.  By  Irving  S.  Haynes,  M.  D.,  Professor  of 
Practical  Anatomy  in  Cornell  University  Medical  College.  680  pages ; 
42  diagrams  and- 134  full-page  half-tone  illustrations  from  original  photo- 
graphs of  the  author's  dissections.     Cloth,  $2.50  net. 

Heisler'S    Embryology.       Second  Edition,  Revised, 

A  Text-Book  of  Embryology.  By  John  C.  Heisler,  M.  D.,  Professor 
of  Anatomy,  Medico-Chirurgical  College,  Philadelphia.  Octavo  volume 
of  405  pages,  handsomely  illustrated.     Cloth,  $2.50  net. 

Hirst's    Obstetrics.       Third  Edition,  Revised  and  Enlarged. 

A  Text-Book  of  Obstetrics.  By  Barton  Cooke  Hirst,  M.  D.,  Professor 
of -Obstetrics,  University  of  Pennsylvania.  Handsome  octavo  volume 
of  873  pages;  704  illustrations,  36  of  them  in  colors.  Cloth,  $5.00  net; 
Sheep  or  Half  Morocco,  $6.00  net. 


MEDICAL   PUBLICATIONS 


Hyde  and  Montgomery  on  Syphilis  and  the  Venereal 

Diseases.       Second  Edition,  Revised  and  Greatly  Enlarged. 

Syphilis  and  the  Venereal  Diseases.  By  James  Nevins  Hyde,  M.  D., 
Professor  of  Skin  and  Venereal  Diseases,  and  Frank  H.  Montgomery, 
M.  D.,  Associate  Professor  of  Skin,  Genito-Urinary,  and  Venereal  Dis- 
eases in  Rush  Medical  College,  Chicago,  111.  Octavo,  594  pages, 
profusely  illustrated.     Cloth,  $4.00  net. 

The  International  Text-Book  of  Surgery.    i„  Two  volumes. 

By  American  and  British  Authors.  Edited  by  J.  Collins  Warren, 
M.  D.,  LL.  D.,  F.  R.  C.  S.  (Hon.),  Professor  of  Surgery,  Harvard  Medi- 
cal School,  Boston ;  and  A.  Pearce  Gould,  M.  S.,  F.  R.  C.  S.,  Lecturer 
on  Practical  Surgery  and  Teacher  of  Operative  Surgery,  Middlesex 
Hospital  Medical  School,  London,  Eng.  Vol.  I.  Genera/  Surgery. — 
Handsome  octavo,  947  pages,  with  458  beautiful  illustrations  and  9 
lithographic  plates.  Vol.  II.  Special  or  Regional  Surgery. — Handsome 
octavo,  1072  pages,  with  471  beautiful  illustrations  and  8  lithographic 
plates.  Sold  by  Subscription.  Prices  per  volume:  Cloth,  $5.00  net; 
Sheep  or  Half  Morocco,  $6.00  net. 

"  It  is  the  most  valuable  work  on  the  subject  that  has  appeared  in  some  years.  The  clini- 
cian and  the  pathologist  have  joined  hands  in  its  production,  and  the  result  must  be  a  satis- 
faction to  the  editors  as  it  is  a  gratification  to  the   conscientious  reader." — Annals  of  Surgery. 

"  This  is  a  work  which  comes  to  us  on  its  own  intrinsic  merits.  Of  the  latter  it  has  very- 
many.  The  arrangement  of  subjects  is  excellent,  and  their  treatment  by  the  different  authors 
is  equally  so.  What  is  especially  to  be  recommended  is  the  painstaking  endeavor  of  each 
writer  to  make  his  subject  clear  and  to  the  point.  To  this  end  particularly  is  the  technique 
of  operations  lucidly  described  in  all  necessary  detail.  And  withal  the  work  is  up  to  date  in 
a  very  remarkable  degree,  many  of  the  latest  operations  in  the  different  regional  parts  of  the 
body  being  given  in  full  details.  There  is  not  a  chapter  in  the  work  from  which  the  reader 
may  not  learn  something  new." — Medical  Record,  New  York. 

Jackson's  Diseases  of  the  Eye. 

A  Manual  of  Diseases  of  the  Eye.  By  Edward  Jackson,  A.  M.,  M.  D., 
Emeritus  Professor  of  Diseases  of  the  Eye,  Philadelphia  Polyclinic  and 
College  for  Graduates  in  Medicine.  12H10  volume  of  535  pages,  with 
178  illustrations,  mostly  from  drawings  by  the  author.    Cloth,  $2.50  net. 

Keating's  Life  Insurance. 

How  to  Examine  for  Life  Insurance.  By  John  M.  Keating,  M.  D., 
Fellow  of  the  College  of  Physicians  of  Philadelphia ;  Ex-President  of  the 
Association  of  Life  Insurance  Medical  Directors.  Royal  octavo,  211 
pages.     With  numerous  illustrations.     Cloth,  $2.00  net. 

Keen  on  the  Surg'ery  of  Typhoid  Fever. 

The  Surgical  Complications  and  Sequels  of  Typhoid  Fever.  By  Wm. 
W.  Keen,  M.  D.,  LL.  D.,  F.  R.  C.  S.  (Hon.),  Professor  of  the  Principles 
of  Surgery  and  of  Clinical  Surgery,  Jefferson  Medical  College,  Phila- 
delphia, etc.    Octavo  volume  of  386  pages,  illustrated.    Cloth,  $3.00  net. 

Keen'S    Operation    Blank.      Second  Edition,  Revised  Form. 

An  Operation  Blank,  with  Lists  of  Instruments,  etc.,  Required  in  Vari- 
ous Operations.  Prepared  by  W.  W.  Keen,  M.  D.,  LL.  D.,  F.  R.  C.  S. 
(Hon.),  Professor  of  the  Principles  of  Surgery  and  of  Clinical  Surgery, 
Jefferson  Medical  College,  Philadelphia.  Price  per  pad,  blanks  for  fifty 
operations,  50  cts.  net. 


OF   W.  B.  SAUNDERS   &>    CO. 


Kyle  on  the  Nose  and  Throat,    second  Edition. 

Diseases  of  the  Nose  and  Throat.  By  D.  Braden  Kyle,  M.  D.,  Clinical 
Professor  of  Laryngology  and  Rhinology,  Jefferson  Medical  College, 
Philadelphia.  Octavo,  646  pages;  over  150  illustrations  and  6  litho- 
graphic plates.     Cloth,  $4.00  net;  Sheep  or  Half  Morocco,  $5.00  net. 

Laine's  Temperature  Chart. 

By  D.  T.  Laine,  M.  D.  For  recording  Temperature,  with  columns  for 
daily  amounts  of  Urinary  and  Fecal  Excretions,  Food,  etc.  ;  with  the 
Brand  Treatment  of  Typhoid  Fever  on  the  back  of  each  chart.     Pad  of 

25  charts,  50  cts.  net. 

Levy,  Klemperer,  arid  Eshner's  Clinical  Bacteriology. 

The  Elements  of  Clinical  Bacteriology.  By  Dr.  Ernst  Levy,  Pro- 
fessor in  the  University  of  Strasburg,  and  Felix  Klemperer,  Privat- 
docent  in  the  University  of  Strasburg.  Translated  and  edited  by 
Augustus  A.  Eshner,  M.  D.,  Professor  of  Clinical  Medicine,  Philadel- 
phia Polyclinic.     Octavo,  440  pages,  fully  illustrated.     Cloth,  $2.50  net. 

Lockwood's  Practice  cf  Medicine.         b^SuS/mSn. 

A  Manual  of  the  Practice  of  Medicine.  By  George  B  oe  Lockwood, 
M.  D.,  Attending  Physician  to  Bellevue  Hospital,  New  York.  Octavo, 
847  pages,  illustrated,  including  22  colored  plates.      Cloth,  $4.00  net. 

Long's  Syllabus  of  Gynecology. 

A  Syllabus  of  Gynecology,  arranged  in  Conformity  with  "An  American 
Text-Book  of  Gynecology."  By  J.  W.  Long,  M.  D.,  Professor  of  Dis- 
eases of  Women  and  Children,  Medical  College  of  Virginia,  etc.  Cloth, 
interleaved,  $1.00  net. 

Macdonald's  Surgical  Diagnosis  arid  Treatment. 

Surgical  Diagnosis  and  Treatment.  By  J.  W.  Macdonald,  M.  D. 
Edin.,  F.  R.  C.  S.  Edin.,  Professor  of  Practice  of  Surgery  and  Clinical 
Surgery,  Hamline  University.  Handsome  octavo,  800  pages,  fully  illus- 
trated.    Cloth,  $5.00  net;  Sheep  or  Half  Morocco,  $6.00  net. 

Mallory  and  Wright's  Pathological  Technique. 

Second  Edition,  Revised. 

Pathological  Technique.  A  Practical  Manual  for  Laboratory  Work  in 
Pathology,  Bacteriology,  and  Morbid  Anatomy,  with  chapters  on  Post- 
Mortem  Technique  and  the  Performance  of  Autopsies.  By  Frank  B. 
Mallory,  A.  M.,  M.  D.,  Assistant  Professor  of  Pathology,  Harvard 
University  Medical  School,  Boston;  and  James  H.  Wright,  A.M., 
M.  D.,  Instructor  in  Pathology,  Harvard  University  Medical  School, 
Boston.     Octavo,  432  pages,  fully  illustrated.     Cloth,  $3.00  net. 

McClellan's  Anatomy  in  its  Relation  to  Art. 

Anatomy  in  its  Relation  to  Art.  An  Exposition  of  the  Bones  and 
Muscles  of  the  Human  Body,  with  Reference  to  their  Influence  upon 
its  Actions  and  External  Form.  By  George  McClellan,  M.  D. , 
Professor  of  Anatomy,  Pennsylvania  Academy  of  Fine  Arts.  Hand- 
some quarto  volume,  9  by  11  j4  inches.  Illustrated  with  338  original 
drawings  and  photographs ;  260  pages  of  text.  Dark  Blue  Vellum, 
$10.00  net;  Half  Russia,  $12.00  net. 


MEDICAL   PUBLICATIONS 


McClellan's  Regional  Anatomy. 

Regional  Anatomy  in  its  Relations  to  Medicine  and  Surgery.  By 
George  McClellan,  M.  D. ,  Professor  of  Anatomy,  Pennsylvania  Acad- 
emy of  Fine  Arts.  Two  handsome  quarto  volumes,  884  pages  of  text, 
and  97  full-page  chromo-lithographic  plates,  reproducing  the  author's 
original  dissections.     Cloth,  $12.00  net;  Half  Russia,  $15.00  net. 

McFarland's  Pathogenic  Bacteria.    ^Jj^5?K£lB 

Text-Book  upon  the  Pathogenic  Bacteria.  By  Joseph  McFarland, 
M.  D.,  Professor  of  Pathology  and  Bacteriology,  Medico-Chirurgical 
College  of  Philadelphia,  etc.  Octavo  volume  of  621  pages,  finely 
illustrated.     Cloth,  $3.25  net. 

Meigs  on  Feeding  in  Infancy. 

Feeding  in  Early  Infancy.  By  Arthur  V.  Meigs,  M.  D.  Bound  in 
limp  cloth,  flush  edges,  25  cts.  net. 

Moore's  Orthopedic  Surgery. 

A  Manual  of  Orthopedic  Surgery.  By  James  E.  Moore,  M.  D.,  Pro- 
fessor of  Orthopedics  and  Adjunct  Professor  of  Clinical  Surgery,  Uni- 
versity of  Minnesota,  College  of  Medicine  and  Surgery.  Octavo  volume 
of  356  pages,  handsomely  illustrated.     Cloth,  $2.50  net. 

Morten's  Nurses'  Dictionary. 

Nurses'  Dictionary  of  Medical  Terms  and  Nursing  Treatment.  Con- 
taining Definitions  of  the  Principal  Medical  and  Nursing  Terms  and 
Abbreviations ;  of  the  Instruments,  Drugs,  Diseases,  Accidents,  Treat- 
ments, Operations,  Foods,  Appliances,  etc.  encountered  in  the  ward  or 
in  the  sick-room.  By  Honnor  Morten,  author  of  "How  to  Become 
a  Nurse,"  etc.      i6mo,  140  pages.     Cloth,  $1.00  net. 

Nancrede's  Anatomy  and  Dissection.    Fourth  Edition. 

Essentials  of  Anatomy  and  Manual  of  Practical  Dissection.  By  Charles 
B.  Nancrede,  M.  D.,  LL.  D.,  Professor  of  Surgery  and  of  Clinical  Sur- 
gery, University  of  Michigan,  Ann  Arbor.  Post-octavo,  500  pages,  with 
full-page  lithographic  plates  in  colors  and  nearly  200  illustrations.  Extra 
Cloth  (or  Oilcloth  for  dissection-room),  $2.00  net. 

Nancrede's  Principles  of  Surgery. 

Lectures  on  the  Principles  of  Surgery.  By  Chas.  B.  Nancrede,  M.  D., 
LL.  D.,  Professor  of  Surgery  and  of  Clinical  Surgery,  University  of 
Michigan,  Ann  Arbor.    Octavo,  398  pages,  illustrated.    Cloth,  $2.50  net. 

Norris's  Syllabus  of  Obstetrics.    Third  Edition,  Revised. 

Syllabus  of  Obstetrical  Lectures  in  the  Medical  Department  of  the 
University  of  Pennsylvania.  By  Richard  C.  Norris,  A.  M.,  M.  D., 
Instructor  in  Obstetrics  and  Lecturer  on  Clinical  and  Operative  Obstet- 
rics, University  of  Pennsylvania.  Crown  octavo,  222  pages.  Cloth, 
.interleaved  for  notes,  $2.00  net. 


OF    W.  B.  SAUNDERS   cV    CO. 


Ogden  on  the  Urine. 

Clinical  Examination  of  the  Urine  and  Urinary  Diagnosis.  A  Clinical 
Guide  for  the  Use  of  Practitioners  and  Students  of  Medicine  and  Sur- 
gery. By  J.  Bergen  Ogden,  M.  D.,  Instructor  in  Chemistry,  Harvard 
Medical  School.  Handsome  Octavo,  416  pages,  with  54  illustrations 
and  a  number  of  colored  plates.     Cloth,  $3.00  net. 

Penrose's  Diseases  of  Women.    Fourth  Edition,  Revised. 

A  Text-Book  of  Diseases  of  Women.  By  Charles  B.  Penrose,  M.  D., 
Ph.  D.,  formerly  Professor  of  Gynecology  in  the  University  of  Penn- 
sylvania. Octavo  volume  of  538  pages,  handsomely  illustrated.  Cloth, 
$3-75  net- 

Pryor — Pelvic  Inflammations. 

The  Treatment  of  Pelvic  Inflammations  through  the  Vagina.  By  W. 
R.  Pryor,  M.  D.,  Professor  of  Gynecology,  New  York  Polyclinic. 
i2mo,  248  pages,  handsomely  illustrated.     Cloth,  $2.00  net. 

Pye's  Bandaging. 

Elementary  Bandaging  and  Surgical  Dressing.  With  Directions  con- 
cerning the  Immediate  Treatment  of  Cases  of  Emergency.  By  Walter 
Pye,  F.  R.  C.  S.,  late  Surgeon  to  St.  Mary's  Hospital,  London.  Small 
nmo,  over  80  illustrations.     Cloth,  flexible  covers,  75  cts.  net. 

Pyle's  Personal  Hygiene. 

A  Manual  of  Personal  Hygiene.  Proper  Living  upon  a  Physiologic 
Basis.  Edited  by  Walter  L.  Pyle,  M.  D.,  Assistant  Surgeon  to  the 
Wills  Eye  Hospital,  Philadelphia.  Octavo  volume  of  344  pages,  fully 
illustrated.      Cloth,  $1.50  net. 

Raymond's  Physiology.     .JEtSESfrSS-. 

A  Text-Book  of  Physiology.  By  Joseph  H.  Raymond,  A.  M.,  M.  D., 
Professor  of  Physiology  and  Hygiene  in  the  Long  Island  College 
Hospital,  and  Director  of  Physiology  in  Hoagland  Laboratory,  New 
York.      Octavo,  668  pages,  443  illustrations.     Cloth,  $3.50  net. 

Salinger  and  Kalteyer's  Modern  Medicine. 

Modern  Medicine.  By  Julius  L.  Salinger,  M.  D.,  Demonstrator  of 
Clinical  Medicine,  Jefferson  Medical  College ;  and  F.  J.  Kalteyer, 
M.  D.,  Assistant  Demonstrator  of  Clinical  Medicine,  Jefferson  Medical 
College.     Handsome  octavo,  801  pages,  illustrated.     Cloth,  $4.00  net. 

Saundby's  Renal  and  Urinary  Diseases. 

Lectures  on  Renal  and  Urinary  Diseases.  By  Robert  Saundby,  M.  D. 
Edin.,  Fellow  of  the  Royal  College  of  Physicians,  London,  and  of  the 
Royal  Medico-Chirurgical  Society ;  Professor  of  Medicine  in  Mason 
College,  Birmingham,  etc.  Octavo,  434  pages,  with  numerous  illustra- 
tions and  4  colored  plates.     Cloth,  $2.50  net. 

Saunders'  Medical  Hand- Atlases. 

See  pages  1 6  and  1 7. 


12  MEDICAL   PUBLICATIONS 


Saunders'  Pocket  Medical  Formulary,  sixth  Edition,  Revised. 

By  William  M.  Powell,  M.  D.,  author  of  "Essentials  of  Diseases  of 
Children":  Member  of  Philadelphia  Pathological  Society.  Contain- 
ing 1844  formulae  from  the  best-known  authorities.  With  an  Appendix 
containing  Posological  Table,  Formulae  and  Doses  for  Hypodermic 
Medication,  Poisons  and  their  Antidotes,  Diameters  of  the  Female  Pelvis 
and  Fetal  Head,  Obstetrical  Table,  Diet  Lists,  Materials  and  Drugs 
used  in  Antiseptic  Surgery,  Treatment  of  Asphyxia  from  Drowning,  Sur- 
gical Remembrancer,  Tables  of  Incompatibles,  Eruptive  Fevers,  etc.,  etc. 
In  flexible  morocco,  with  side  index,  wallet,  and  flap.     $2.00  net. 

Saunders'  Question-Compends.     See  page  15= 

Scudder'S    Fractures.       Second  Edition,  Revised. 

The  Treatment  of  Fractures.  By  Chas.  L.  Scudder,  M.  D.,  Assistant 
in  Clinical  and  Operative  Surgery,  Harvard  University  Medical  School. 
Octavo,  460  pages,  with  nearly  600  original  illustrations.  Polished 
Buckram,  #4.50  net;    Half  Morocco,  $5.50  net. 

Senn's  Genito-Urinary  Tuberculosis. 

Tuberculosis  of  the  Genito-Urinary  Organs,  Male  and  Female.  By 
Nicholas  Senn,  M.  D.,  Ph.  D.,  LL.  D.,  Professor  of  the  Practice  of 
Surgery  and  of  Clinical  Surgery,  Rush  Medical  College,  Chicago. 
Handsome  octavo  volume  of  320  pages,  illustrated.     Cloth,  $3.00  net. 

Senn's  Practical  Surgery. 

Practical  Surgery.  By  Nicholas  Senn,  M.  D.,  Ph.  D.,  LL.  D.,  Pro- 
fessor of  the  Practice  of  Surgery  and  of  Clinical  Surgery,  Rush  Medical 
College,  Chicago.  Octavo,  1133  pages,  642  illustrations.  Cloth,  $6.00 
net;   Sheep  or  Half  Morocco,  S7.00  net.     By  Subscription. 

Senn's  Syllabus  qf  Surgery. 

A  Syllabus  of  Lectures  on  the  Practice  of  Surgery,  arranged  in  con- 
formity with  ••'An  American  Text-Book  of  Surgery."  By  Nicholas 
Senn,  M.  D.,  Ph.  D.,  LL.  D.,  Professor  of  the  Practice  of  Surgery  and 
of  Clinical  Surgery,  Rush  Medical  College,  Chicago.     Cloth,  $1.50  net. 

Senn's    TumOrS.       Second  Edition,  Revised. 

Pathology  and  Surgical  Treatment  of  Tumors.  By  Nicholas  Senn,  M.  D. , 
Ph.  D.,  LL.  D.,  Professor  of  the  Practice  of  Surgery  and  of  Clinical 
Surgery,  Rush  Medical  College,  Chicago.  Octavo  volume  of  718  pages, 
with  478  illustrations,  including  12  full-page  plates  in  colors.  Cloth, 
$5.00  net;  Sheep  or  Half  Morocco,  $6.00  net. 

Sollmann's  Pharmacology. 

A  Text-Book  of  Pharmacology  :  including  Therapeutics,  Materia  Medica, 
Pharmacy,  Prescription- Writing,  Toxicology,  etc.  By  Torald  Soll- 
mann,  M.  D.,  Assistant  Professor  of  Pharmacology  and  Materia  Medica, 
Western  Reserve  University,  Cleveland,  Ohio.  Handsome  octavo, 
894  pages,  fully  illustrated.     Cloth,  $3. 75  net. 


OF   W.  B.  SAUNDERS   &    CO.  13 


Starr's  Diets  for  Infants  arid  Children. 

Diets  for  Infants  and  Children  in  Health  and  in  Disease.  By  Louis 
Starr,  M.  D.,  Editor  of  "An  American  Text-Book  of  the  Diseases  of 
Children."  230  blanks  (pocket-book  size),  perforated  and  neatly  bound 
in  flexible  morocco.     $1.25  net. 

Stengel's    Pathology.       Third  Edition,  Thoroughly  Revised. 

A  Text-Book  of  Pathology.  By  Alfred  Stengel,  M.  D.,  Professor  of 
Clinical  Medicine,  University  of  Pennsylvania;  Visiting  Physician  to 
the  Pennsylvania  Hospital.  Handsome  octavo,  873  pages,  nearly  400 
illustrations,  many  of  them  in  colors.  Cloth,  $5.00  net;  Sheep  or  Half 
Morocco,  $6.00  net. 

Stengel  arid  White  on  the  Blood. 

The  Blood  in  its  Clinical  and  Pathological  Relations.  By  Alfred 
Stengel,  M.  D.,  Professor  of  Clinical  Medicine,  University  of  Penn- 
sylvania ;  and  C.  Y.  White,  Jr.,  M.  D.,  Instructor  in  Clinical  Medicine, 
University  of  Pennsylvania.      /;/  Press. 

Stevens'    Therapeutics.       Rewritten  and  Greatly  Enlarged. 

A  Text-Book  of  Modern  Therapeutics.  By  A.  A.  Stevens,  A.  M.,  M.  D., 
Lecturer  on  Physical  Diagnosis  in  the  University  of  Pennsylvania. 

Stevens'  Practice  of  Medicine.    Fifth  Edition,  Revised. 

A  Manual  of  the  Practice  of  Medicine.  By  A.  A.  Stevens,  A.  M., 
M.  D.,  Lecturer  on  Physical  Diagnosis  in  the  University  of  Pennsyl- 
vania.' Specially  intended  for  students  preparing  for  graduation  and 
hospital  examinations.  Post-octavo,  519  pages;  illustrated.  Flexible 
Leather,  $2.00  net. 

Stewart's    Physiology.       Fourth  Edition,  Revised. 

A  Manual  of  Physiology,  with  Practical  Exercises.  For  Students  and 
Practitioners.  By  G.  N.  Stewart,  M.  A.,  M.  D.,  D.  Sc,  Professor  of 
Physiology  in  the  Western  Reserve  University,  Cleveland,  Ohio.  Octavo 
volume  of  894  pages;   336  illustrations  and  5  colored  plates.     Cloth, 

$3-75  net- 

Stoney's  Materia  Medica  for  Nurses. 

Materia  Medica  for  Nurses.  By  Emily  A.  M.  Stoney,  late  Superintend- 
ent of  the  Training-School  for  Nurses,  Carney  Hospital,  South  Boston, 
Mass.     Handsome  octavo  volume  of  306  pages.     Cloth,  #1.50  net. 

StOney'S    Nursing.      Second  Edition,  Revised. 

Practical  Points  in  Nursing.  For  Nurses  in  Private  Practice.  By  Emily 
A.  M.  Stoney,  late  Superintendent  of  the  Training-School  for  Nurses, 
Carney  Hospital,  South  Boston,  Mass.  456  pages,  with  73  engravings 
and  8  colored  and  half-tone  plates.     Cloth,  $1.75  net. 

Stoney's  Surgical  Technic  for  Nurses. 

Bacteriology  and  Surgical  Technic  for  Nurses.  By  Emily  A.  M.  Stoney, 
late  Superintendent  of  the  Training-School  for  Nurses,  Carney  Hospital, 
South  Boston,  Mass.     i2mo  volume,  fully  illustrated.     Cloth,  $1.25  net. 


i4  MEDICAL   PUBLICATIONS. 

Thomas's    Diet   ListS.      Second  Edition,  Revised. 

Diet  Lists  and  Sick-Room  Dietary.  By  Jerome  B.  Thomas,  M.  D., 
Visiting  Physician  to  the  Home  for  Friendless  Women  and  Children 
and  to  the  Newsboys'  Home ;  Assistant  Visiting  Physician  to  the  Kings 
County  Hospital.     Cloth,  $1.25  net.     Send  fi  r  sample  sheet. 

Thornton's  Dose-Book  ant  Prescription-Writing. 

Second  Edition,  Revised  and  Enlarged. 

Dose-Book  and  Manual  of  Prescription-Writing.  By  E.  Q.  Thornton, 
M.  D.,  Demonstrator  of  Therapeutics,  Jefferson  Medical  College,  Phila. 
Post-octavo,  362  pages,  illustrated.      Flexible  Leather,  $2.00  net. 

Vecki'S    SeXtial    Impotence.        Third  Edition,  Revised  and  Enlarged. 

The  Pathology  and  Treatment  of  Sexual  Impotence.  By  Victor  G. 
Vecki,  M.  D.  From  the  second  German  edition,  revised  and  enlarged. 
Demi-octavo,  329  pages.     Cloth,  $2.00  net. 

Vierordt's  Medical  Diagnosis.    Fourth  Edition,  Revised. 

Medical  Diagnosis.  By  Dr.  Oswald  Vierordt,  Professor  of  Medicine, 
University  of  Heidelberg.  Translated,  with  additions,  from  the  fifth 
enlarged  German  edition,  with  the  author's  permission,  by  Francis  H. 
Stuart,  A.M.,  M.  D.  Handsome  octavo  volume,  603  pages;  194 
wood-cuts,  many  of  them  in  colors.  Cloth,  $4.00  net;  Sheep  or  Half 
Morocco,  $5.00  net. 

Watson's  Handbook  for  Nurses. 

A  Handbook  for  Nurses.  By  J.  K.  Watson,  M.  D.  Edin.  American 
Edition,  under  supervision  of  A.  A.  Stevens,  A.M.,  M.  D.,  Lecturer 
on  Physical  Diagnosis,  University  of  Pennsylvania.  121110,  413  pages, 
73  illustrations.     Cloth,  $1.50  net. 

Warren's  Surgical  Pathology,     second  Edition. 

Surgical  Pathology  and  Therapeutics.  By  John  Collins  Warren, 
M.  D.,  LL.  D.,  F.  R.  C.  S.  (Hon.),  Professor  of  Surgery,  Harvard 
Medical  School.  Handsome  octavo,  873  pages;  136  relief  and  litho- 
graphic illustrations,  33  in  colors.  With  an  Appendix  on  Scientific 
Aids  to  Surgical  Diagnosis,  and  a  series  of  articles  on  Regional  Bacte- 
riology.    Cloth,  $5.00  net;    Sheep  or  Half  Morocco,  $6.00  net. 

Warwick  and  Tunstall's  First  Aid  to  the  Injured  and 
Sick. 

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Cantab.,  M.  R.  C.  S.,  Surgeon-Captain,  Vohmteer  Medical  Staff  Corps, 
London  Companies;  and  A.  C.  Tunstall,  M.  D.,  F.  R.  C.  S.  Ed., 
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Company.     i6mo,  232  pages;  nearly  200  illustrations.    Cloth,  $1.00  net. 

Wolf's  Examination  qf   Urine. 

A  Handbook  of  Physiologic  Chemistry  and  Urine  Examination.  By 
Chas.  G.  L.  Wolf,  M.  D.,  Instructor  in  Physiologic  Chemistry,  Cornell 
University  Medical  College.  121110,  204  pages,  illustrated.  Cloth,  #1.25 
net. 


SAUNDERS' 
QUESTION-COMPEND  SCRIES. 

Price,  Cloth,  $1.00  net  per  copy,  except  when  otherwise  noted. 


"  Where  the  work  of  preparing  students'  manuals  is  to  end  we  cannot  say,  but  the  Saunders  Series, 
in  our  opinion,  bears  off  the  palm  at  present." — New  York  Medical  Record. 

1.  Essentials  of  Physiology.     By  Sidney  Budgett,  M.  D.     A  New  Work. 

2.  Essentials  of  Surgery.     By  Edward  Martin,  M.  D.     Seventh  edition,  revised,  with 

an  Appendix  and  a  chapter  on  Appendicitis. 

3.  Essentials  of  Anatomy.     By   Charles    B.    Nancrede,    M.  D.     Sixth   edition,  thor- 

oughly revised  and  enlarged. 

4.  Essentials  of  Medical  Chemistry,  Organic  and  Inorganic.     By  Lawrence  Wolff, 

M.  D.      Fifth  edition,  revised. 

5.  Essentials  of  Obstetrics.     By  W.  Easterly  Ashton,  M.  D.    Fourth  edition,  revised 

and  enlarged. 

6.  Essentials  of  Pathology  and  Morbid  Anatomy.     By  F.  J.  Kalteyer,  M.  D.     In 

preparation. 

7.  Essentials  of  Materia  Medica,  Therapeutics,  and  Prescription-Writing.    By  Henry 

Morris,  M.  D.     Fifth  edition,  revised. 

8.  9.    Essentials  of  Practice  of  Medicine.     By  Henry  Morris,  M.  D.     An  Appendix 

on  Urine  Examination.  By  Lawrence  Wolff,  M.  D.  Third  edition,  enlarged 
by  some  300  Essential  Formulae,  selected  from  eminent  authorities,  by  Wm,  M. 
Powell,  M.  D.     (Double  number,  $1.50  net.) 

10.  Essentials  of  Gynecology.     By  Edwin  B.  Cragin,  M.  D.     Fifth  edition,  revised. 

11.  Essentials  of  Diseases  of  the  Skin.     By  Henry  W.  Stelwagon,  M.  D.     Fourth 

edition,  revised  and  enlarged. 

12.  Essentials  of  Minor  Surgery,  Bandaging,  and  Venereal    Diseases.     By  Edward 

Martin,  M.  D.     Second  edition,  revised  and  enlarged. 

13.  Essentials    of    Legal    Medicine,   Toxicology,    and    Hygiene.     This   volume   is   at 

present  out  of  print. 

14.  Essentials  of  Diseases  of  the  Eye.     By  Edward  Jackson,  M.  D.     Third  edition, 

revised  and  enlarged. 

15.  Essentials  of  Diseases  of  Children.    By  William  M.  Powell,  M.  D.    Third  edition. 

16.  Essentials    of    Examination    of    Urine.     By   Lawrence   Wolff,   M.  D.      Colored 

'•  Vogel  Scale."     (75  cents  net.) 

17.  Essentials  of  Diagnosis.     By  S.   Solis-Cohen,  M.  D.,  and  A.   A.  Eshner,  M.  D. 

Second  edition,  thoroughly  revised. 

18.  Essentials    of    Practice    of    Pharmacy.     By  Lucius   E.    Sayre.     Second   edition, 

revised  and  enlarged. 

19-    Essentials  of  Diseases  of  the  Nose  and  Throat.     By  E.  B.  Gleason,  M.  D.     Third 
edition,  revised  and  enlarged. 

20.  Essentials  of  Bacteriology.     By  M.  V.  Ball,  M.  D.     Fourth  edition,  revised. 

21.  Essentials  of  Nervous  Diseases  and  Insanity.     By  John  C.  Shaw,  M.  D.     Third 

edition,  revised. 

22.  Essentials  of    Medical    Physics.     By  Fred  J.   Brockway,  M.  D.     Second  edition, 

revised. 

23.  Essentials  of  Medical  Electricity.     By  David  D.  Stewart,  M.  D.,  and  Edward 

S.  Lawrance,  M.  D. 

24.  Essentials  of  Diseases  of  the  Ear.     By   E.  B.   Gleason,   M.  D.     Second   edition, 

revised  and  greatly  enlarged. 

25.  Essentials  of  Histology.     By  Louis  Leroy,  M.  D.     With  73  original  illustrations. 


Pamphlet  containing  specimen  pages,  etc.,  sent  free  upon  application. 


Saunders'  Medical    Hand-Atlases. 

VOLUMES   NOW   READY. 

Atlas  and  Epitome  of  Internal  Medicine  and  Clinical 
Diagnosis. 

By  Dr.  Chr.  Jakob,  of  Erlangen.  Edited  by  Augustus  A.  Eshner, 
M.  D.,  Professor  of  Clinical  Medicine,  Philadelphia  Polyclinic.  With 
179  colored  figures  on  68  plates,  64  text-illustrations,  259  pages  of  text. 
Cloth,  $3.00  net. 

Atlas  of  Legal  Medicine. 

By  Dr.  E.  R.  von  Hofmann,  of  Vienna.  Edited  by  Frederick 
Peterson,  M.  D.,  Chief  of  Clinic,  Nervous  Department,  College  of 
Physicians  and  Surgeons,  New  York.  With  120  colored  figures  on  56 
plates  and  193  beautiful  half-tone  illustrations.     Cloth,  $3.50  net. 

Atlas  and  Epitome  of  Diseases  of  the  Larynx. 

By  Dr.  L.  Grunwald,  of  Munich.  Edited  by  Charles  P.  Grayson, 
M.  D. ,  Physician -in-Charge,  Throat  and  Nose  Department,  Hospital  of 
the  University  of  Pennsylvania.  With  107  colored  figures  on  44  plates, 
25  text-illustrations,  and  103  pages  of  text.     Cloth,  $2.50  net. 

Atlas  and  Epitome  of  Operative  Surgery. 

By  Dr.  O.  Zuckerkandl,  of  Vienna.  Edited  by  J.  Chalmers 
DaCosta,  M.  D.,  Professor  of  Principles  of  Surgery  and  Clinical  Sur- 
gery, Jefferson  Medical  College,  Philadelphia.  With  24  colored  plates, 
217  text-illustrations,  and  395  pages  of  text.     Cloth,  $3.00  net. 

Atlas   and   Epitome   of    Syphilis    and  the   Venereal 
Diseases. 

By  Prof.  Dr.  Franz  Mracek,  of  Vienna.  Edited  by  L.  Bolton 
Bangs,  M.  D.,  Professor  of  Genito-Urinary  Surgery,  University  and 
Bellevue  Hospital  Medical  College,  New  York.  With  71  colored 
plates,  16  illustrations,  and  122  pages  of  text.     Cloth,  $3.50  net. 

Atlas  and  Epitome  of  External  Diseases  of  the  Eye. 

By  Dr.  0.  Haab,  of  Zurich.  Edited  by  G.  E.  de  Schweinitz,  M.  D., 
Professor  of  Ophthalmology,  Jefferson  Medical  College,  Phila.  With  76 
colored  figures  on  40  plates;  228  pages  of  text.     Cloth,  $3.00  net. 

Atlas  and  Epitome  of  Skin  Diseases. 

By  Prof.  Dr.  Franz  Mracek,  of  Vienna.  Edited  by  Henry  W.  Stel- 
wagon,  M.  D.,  Clinical  Professor  of  Dermatology,  Jefferson  Medical 
College,  Philadelphia.  With  63  colored  plates,  39  half-tone  illustra- 
tions, and  200  pages  of  text.     Cloth,  $3.50  net. 

Atlas  and  Epitome  of  Special  Pathological  Histology. 

By  Dr.  H.  Durck,  of  Munich.  Edited  by  Ludvig  Hektoen,  M.  D., 
Professor  of  Pathology,  Rush  Medical  College,  Chicago.  In  Two  Parts. 
Part  I.,  including  Circulatory,  Respiratory,  and  Gastro-intestinal  Tracts, 
120  colored  figures  on  62  plates,  158  pages  of  text.  Part  II. ,  including 
Liver,  Urinary  Organs,  Sexual  Organs,  Nervous  System,  Skin,  Muscles, 
and  Bones,  123  colored  figures  on  60  plates,  and  192  pages  of  text. 
Per  part:   Cloth,  $3.00  net. 

16 


Saunders'  Medical  Hand-Atlases. 


VOLUMES   JUST   ISSUED. 

Atlas  and  Epitome  of  Diseases  Caused  by  Accidents. 

By  Dr.  Ed.  Golebiewski,  of  Berlin.  Translated  and  edited  with  addi- 
tions by  Pearce  Bailey,  M.  D.,  Attending  Physician  to  the  Department 
of  Corrections  and  to  the  Almshouse  and  Incurable  Hospitals,  New 
York.  With  40  colored  plates,  143  text-illustrations,  and  600  pages 
of  text.     Cloth,  $4.00  net. 

Atlas  and  Epitome  of  Gynecology. 

By  Dr.  O.  Shaeffer,  of  Heidelberg.  From  the  Second  Revised  Ger- 
man Edition.  Edited  by  Richard  C.  Norris,  A.  M.,  M.  D.,  Gyne- 
cologist to  the  Methodist  Episcopal  and  the  Philadelphia  Hospitals ; 
Surgeon-in-Charge  of  Preston  Retreat,  Philadelphia.  With  90  colored 
plates,  65  text-illustrations,  and  308  pages  of  text.     Cloth,  $3.50  net. 

Atlas   and  Epitome  of  the  Nervous  System  and  its 
Diseases. 

By  Professor  Dr.  Chr.  Jakob,  of  Erlangen.  From  the  Second  Re- 
vised and  Enlarged  German  Edition.  Edited  by  Edward  D.  Fisher, 
M.  D.,  Professor  of  Diseases  of  the  Nervous  System,  University  and 
Bellevue  Hospital  Medical  College,  New  York.  With  83  plates  and  a 
copious  text.     Cloth,  $3.50  net. 

Atlas  and  Epitome  of  Labor  and  Operative  Obstetrics. 

By  Dr.  O.  Schaeffer,  of  Heidelberg.  From  the  Fifth  Revised  and 
Enlarged  German  Edition.  Edited  by  J.  Clifton  Edgar,  M.  D., 
Professor  of  Obstetrics  and  Clinical  Midwifery,  Cornell  University 
Medical  School.      With  126  colored  illustrations.      Cloth,  $2.00  net. 

Atlas    and    Epitome    of    Obstetric     Diagnosis    and 
Treatment. 

By  Dr.  O.  Schaeffer,  of  Heidelberg.  From  the  Second  Revised  and  En- 
larged German  Edition.  Edited  by  J.  Clifton  Edgar,  M.  D.,  Professor 
of  Obstetrics  and  Clinical  Midwifery,  Cornell  University  Medical  School. 
72  colored  plates,  text-illustrations,  and  copious  text.      Cloth,  $3.00  net. 

Atlas   and   Epitome   of   Ophthalmoscopy  and    Oph- 
thalmoscopic   Diagnosis. 

By  Dr.  O.  Haab,  of  Zurich.  From  the  Third  Revised  and  Enlarged 
German  Edition.  Edited  by  G.  E.  de  Schweinitz,  M.  D.,  Professor 
of  Ophthalmology,  Jefferson  Medical  College,  Philadelphia.  With  152 
colored  figures  and  82  pages  of  text.      Cloth,  $3.00  net. 

Atlas  and  Epitome  of  Bacteriology. 

Including  a  Text-Book  of  Special  Bacteriologic  Diagnosis.  By  Prof. 
Dr.  K.  B.  Lehmann  and  Dr.  R.  O.  Neumann,  of  Wurzburg.  From  the 
Second  Revised  German  Edition.  Edited  by  George  H.  Weaver,  M.  D., 
Assistant  Professor  of  Pathology  and  Bacteriology,  Rush  Medical  College, 
Chicago.  In  Two  Parts.  Part  I.,  consisting  of  632  colored  illustra- 
tions on  69  lithographic  plates.  Part  II.,  consisting  of  5  1 1  pages  of 
text,  illustrated.     Per  set :   Cloth,  $5.00  net. 


ADDITIONAL  VOLUMES  IN    PREPARATION. 

17 


NOTHNAGEL'S  ENCYCLOPEDIA 

OF 

PRACTICAL  MEDICINE 

Edited  by  ALFRED   STENGEL,  M.  D. 

Professor  of  Clinical  Medicine  in  the  University  of  Pennsylvania ;  Visiting 
Physician  to  the  Pennsylvania  Hospital 

IT  is  universally  acknowledged  that  the  Germans  lead  the  world  in  Internal 
Medicine  ;  and  of  all  the  German  works  on  this  subject,  Nothnagel's  "  Ency- 
clopedia of  Special  Pathology  and  Therapeutics"  is  conceded  by  scholars  to 
be  without  question  the  best  System  of  Medicine  in  existence.  So  necessary 
is  this  book  in  the  study  of  Internal  Medicine  that  it  comes  largely  to  this  country 
in  the  original  German.  In  view  of  these  facts,  Messrs.  W.  B.  Saunders  &  Com- 
pany have  arranged  with  the  publishers  to  issue  at  once  an  authorized  edition 
of  this  great  encyclopedia  of  medicine  in  English. 

For  the  present  a  set  of  some  ten  or  twelve  volumes,  representing  the  most 
practical  part  of  this  encyclopedia,  and  selected  with  especial  thought  of  the  needs 
of  the  practical  physician,  will  be  published.  The  volumes  will  contain  the  real 
essence  of  the  entire  work,  and  the  purchaser  will  therefore  obtain  at  less  than 
half  the  cost  the  cream  of  the  original.  Later  the  special  and  more  strictly 
scientific  volumes  will   be  offered  from  time  to  time. 

The  work  will  be  translated  by  men  possessing  thorough  knowledge  of  both 
English  and  German,  and  each  volume  will  be  edited  by  a  prominent  specialist 
on  the  subject  to  which  it  is  devoted.  It  will  thus  be  brought  thoroughly  up  to 
date,  and  the  American  edition  will  be  more  than  a  mere  translation  of  the  Ger- 
man ;  for,  in  addition  to  the  matter  contained  in  the  original,  it  will  represent  the 
very  latest  views  of  the  leading  American  specialists  in  the  various  departments 
of  Internal  Medicine.  The  whole  System  will  be  under  the  editorial  super- 
vision of  Dr.  Alfred  Stengel,  who  will  select  the  subjects  for  the  American  edition, 
and  will  choose  the  editors  of  the  different  volumes. 

Unlike  most  encyclopedias,  the  publication  of  this  work  will  not  be  extended 
over  a  number  of  years,  but  five  or  six  volumes  will  be  issued  during  the  coming 
year,  and  the  remainder  of  the  series  at  the  same  rate.  Moreover,  each  volume 
will  be  revised  to  the  date  of  its  publicatfon  by  the  American  editor.  This  will 
obviate  the  objection  that  has  heretofore  existed  to  systems  published  in  a  number 
of  volumes,  since  the  subscriber  will  receive  the  completed  work  while  the  earlier 
volumes  are  still  fresh. 

The  usual  method  of  publishers,  when  issuing  a  work  of  this  kind,  has  been 
to  compel  physicians  to  take  the  entire  System.  This  seems  to  us  in  many  cases 
to  be  undesirable.  Therefore,  in  purchasing  this  enc}rclopedia,  physicians  will  be 
given  the  opportunity  of  subscribing  for  the  entire  System  at  one  time  ;  but  any 
single  volume  or  any  number  of  volumes  may  be  obtained  by  those  who  do  not 
desire  the  complete  series.  This  latter  method,  while  not  so  profitable  to  the  pub- 
lisher, offers  to  the  purchaser  many  advantages  which  will  be  appreciated  by  those 
who  do  not  care  to  subscribe  for  the  entire  work  at  one  time. 

This  American  edition  of  Nothnagel's  Encyclopedia  will,  without  question, 
form  the  greatest  System  of  Medicine  ever  produced,  and  the  publishers  feel  con- 
fident that  it  will  meet  with  general  favor  in  the  medical  profession. 

18 


NOTHNAGEL'S  ENCYCLOPEDIA 

VOLUMES  JUST  ISSUED  AND  IN  PRESS 


VOLUME  I 
Editor,  William  Osier,  M.D.,  F.R.C.P. 

Professor  of  Medicine  in  Johns  Hopkins 
University 

CONTENTS 
Typhoid  Fever.     By  Dr.  H.  Curschmann, 
of  Leipsic.     Typhus  Fever.     By  Dr.  H. 
Curschmann,  of  Leipsic. 

Handsome  octavo  volume  of  about  600  pages. 
Just  Issued 


VOLUME  II 

Editor,  Sir  J.  W.  Moore,  B.  A.,  M.D., 
F.R.C.P.I.,  of  Dublin 

Professor  of  Practice  of  Medicine,  Royal  College 
of  Surgeons  in  Ireland 

CONTENTS 

Erysipelas  and  Erysipeloid.  By  Dr.  H.Len- 
hartz,  of  Hamburg.  Cholera  Asiatica  and 
Cholera  Nostras.  By  Dr.  K.  von  Lieber- 
meister,  of  Tubingen.  "Whoooing  Cough 
and  Hay  Fever.  By  Dr.  G.  Sticker,  of 
Giessen.  Varicella.  By  Dr.  Th.  von  Jur- 
gensen,  of  Tiibingen.  Variola  (including 
Vaccination).  By  Dr.  H.  Immermann,  of 
Basle. 

Handsome  octavo  volume  of  over  700  pages. 
Just  Issued 


VOLUME  VII 
Editor,  John  H.  Musser,  M.  D. 

Professor  of  Clinical  Medicine,  University  of 
Pennsylvania. 

CONTENTS 

Diseases  of  the  Bronchi.  By  Dr.  F.  A.  Hoff- 
mann, of  Leipsic.  Diseases  of  the  Pleura. 
By  Dr.  Rosenbach,  of  Berlin.  Pneumonia. 
By  Dr.  E.  Aufrecht,  of  Magdeburg. 


VOLUME  VIII 
Editor,  Charles  G.  Stockton,  M.D. 

Professor  of  Medicine,  University  of  Buffalo 

CONTENTS 

Diseases  of  the  Stomach.    By  Dr.  F.  Riegel, 

of  Giessen. 


VOLUME  DC 
Editor,  Frederick  A.  Packard,  M.  D. 

Physician  to  the  Pennsylvania  Hospital  and  to  the 
Children's  Hospital,  Philadelphia 

CONTENTS 

Diseases  of  the  Liver.    By  Dks.  H.  Quincke 
and  G.  Hoppe-Seyler,  of  Kiel. 


volume  in 

Editor,  William  P.  Northrup,  M.  D. 

Professor  of  Pediatrics ,  University  and  Bellevue 
Medical  College 

CONTENTS 

Measles.  By  Dr.  Th.  von  Jurgensen,  of 
Tubingen.  Scarlet  Fever.  By  the  same 
author.     Rbtheln.    By  the  same  author. 


VOLUME  X 
Editor,  Reginald  H.  Fitz,  A.M.,  M.  D. 

Hersey  Professor  of  the  Theory  and  Practice 
of  Physic,  Plarvard  University 

CONTENTS 

Diseases  of  the  Pancreas.  By  Dr.  L.  Oser, 
of  Vienna.  Diseases  of  the  Suprarenals. 
By  Dr.  E.  Neusser,  of  Vienna. 


VOLUME  VI 
Editor,  Alfred  Stengel,  M.D. 

Professor  of  Clinical  Medicine ,  University  of 
Pennsylvania 

CONTENTS 

Anemia.  By  Dr.  P.  Ehrljch,  of  Frankfort - 
on-the-Main,  and  Dr.  A.  Lazarus,  of  Char- 
lottenburg.  Chlorosis.  By  Dr.  K.  von 
Noorden,  of  Frankfort-on-the-Main.  Dis- 
eases of  the  Spleen  and  Hemorrhagic 
Diathesis.   By  Dr.  M.  Litten,  of  Berlin. 


VOLUMES  IV,  V,  and  XI 
Editors  announced  later 

Vol.  IV.— Influenza  and  Dengue.  By  Dr.  O. 

Leichtenstern,  of  Cologne.  MalarialDis- 
eases.  By  Dr.  J.  Mannaberg,  of  Vienna. 
Vol.  V. — Tuberculosis  and  Acute  General 
Miliary  Tuberculosis.  By  Dr.  G.  Cornet, 
of  Berlin. 

Vol.  XL — Diseases  of  the  Intestines  and 
Peritoneum.  By  Dr.  H.  Nothnagel, 
of  Vienna. 


CLASSIFIED   LIST 

OF  THE 

MEDICAL    PUBLICATIONS 


OF 


W.  B.  SAUNDERS  &  COMPANY 


ANATOMY,  EMBRYOLOGY, 

HISTOLOGY. 

Bbhm,  Davidoff,  andHuber — Histology,  .  4 
Clarkson — A  Text-Book  of  Histology,  .  .  5 
Haynes— A  Manual  of  Anatomy,  ....  7 
Heisler — A  Text-Book  of  Embryology,  .  .  7 
Leroy — Essentials  of  Histology,  .    . 

McClellan — Art  Anatomy 

McClellan — Regional  Anatomy,  .    . 
Nancrede — Essentials  of  Anatomy, . 
Nancrede — Essentials    of     Anatomy    and 
Manual  of  Practical   Dissection 10 

BACTERIOLOGY. 

Ball — Essentials  of  Bacteriology, 15 

Frothingham — Laboratory  Guide,  ....  6 
Gorham — Laboratory  Bacteriology,    ...  6 
Lelimann  and  Neumann — Atlas  of  Bacte- 
riology,     17 

Levy  and  Klemperer's  Clinical  Bacteri- 
ology   9 

Mallory  and  Wright — Pathological  Tech- 
nique   9 

McFarland — Pathogenic  Bacteria 10 

CHARTS,  DIET-LISTS,  ETC. 

Griffith — Infant's  Weight  Chart 7 

Hart — Diet  in  Sickness  and  in  Health,  .    .  7 

Keen — Operation  Blank 8 

Laine — Temperature  Chart 9 

Meigs — Feeding  in  Early  Infancy 10 

Starr — Diets  for  Infants  and  Children,  .    .  13 

Thomas — Diet-Lists 14 

CHEMISTRY  AND  PHYSICS. 

Brockway— Essentials  of  Medical  Physics, 
Jelliflfe  and  Diekman — Chemistry,    .    .    . 

Wolf — Urine  Examination 

Wolff — Essentials  of  Medical  Chemistry,  . 

CHILDREN. 
American  Test-Book  Dis.of  Children,  .    . 

Griffith— Care  of  the  Babv 

Griffith— Diseases  of  Children 

Griffith— Infant's  Weight  Chart, 

Meigs — Feeding  in  Early  Infancy 

Powell— Essentials  of  Diseases  of  Children, 
Starr— Diets  for  Infants  and  Children,  .    . 

DIAGNOSIS. 
Cohen  and  Eshner— Essentials  of  Diag- 
nosis  

Corwin — Physical  Diagnosis 

Vierordt — Medical  Diagnosis 


15 


14 


DICTIONARIES. 
The  American  Illustrated  Medical  Dic- 
tionary  

The  American  Pocket  Medical  Dictionary, 
Morten — Nurses'  Dictionary, 


EYE,  EAR,  NOSE,-  AND  THROAT. 

An  American  Text-Book  of  Diseases  of 

the  Eye,  Ear,  Nose,  and  Throat 1 

De  Schweinitz — Diseases  of  the  Eye,    .    .      6 
Friedrich  and  Curtis — Rhinology,  Laryn- 
gology and  Otology 6 

Gleason — Essentials  of  Diseases  of  the  Ear,  15 
Gleason — Ess.  of  Dis.  of  Nose  and  Throat,   15 

Gradle — Ear,  Nose,  and  Throat, 22 

Griinwald   and    Grayson — Atlas  of  Dis- 
eases of  the  Larynx, 16 

Haab  and  De  Schweinitz — Atlas  of  Exter- 
nal Diseases  of  the  Eye 16 

Haab  and  De  Schweinitz — Atlas  of  Oph- 
thalmoscopy,      17 

Jackson — Manual  of  Diseases  of  the  Eye,  8 
Jackson — Essentials  of  Diseases  of  Eye,  15 
Kyle — Diseases  of  the  Nose  and  Throat,  .      9 

GENITO-URINARY. 

An  American  Text-Book  of  Genito-Uri- 

nary  and  Skin  Diseases 2 

Hyde  and  Montgomery — Syphilis  and  the 

Venereal  Diseases 8 

Martin— Essentials     of    Minor    Surgery, 

Bandaging,  and  Venereal  Diseases,  .  .  .  15 
Mracek  and  Bangs — Atlas  of  Syphilis  and 

the  Venereal  Diseases 16 

Saundby — Renal  and  Urinary  Diseases,  .  .  n 
Senn — Genito-Urinary  Tuberculosis,  ...  12 
Vecki — Sexual  Impotence 14 

GYNECOLOGY. 

American  Text-Book  of  Gynecology,    .    .  2 

Cragin — Essentials  of  Gynecology 15 

Garrigues — Diseases  of  Women,  ....  6 

Long — Syllabus  of  Gynecology, 9 

Penrose — Diseases  of  Women, . 
Pryor — Pelvic  Inflammations,  . 
Schaeffer  &  Norris — Atlas  of  Gynecology,  17 

HYGIENE. 

Abbott — Hygiene  of  Transmissible  Diseases    3 

Bergey — Principles  of  Hygiene, 4 

Pyle — Personal  Hygiene 11 

MATERIA  MEDICA,  PHARMACOL- 
OGY, AND  THERAPEUTICS. 

American  Text-Book  of  Therapeutics,  .  .  1 
Butler — Text-Book    of    Materia    Medica, 

Therapeutics,  and  Pharmacology,   ...  4 

Morris — Ess.  of  M.  M.  and  Therapeutics,  15 

Saunders'  Pocket  Medical  Formulary,  .    .  12 

Sayre — Essentials  of  Pharmacy 15 

Sollmann — Text- Book  of  Pharmacology,  .  12 

Stevens — Manual  of  Therapeutics,    ...  13 

Stoney— Materia   Medica  for  Nurses,    .    .  13 

Thornton — Prescription-Writing 14 


MEDICAL  PUBLICATIONS  OF  W.  B.  SAUNDERS  &  CO.    21 


MEDICAL  JURISPRUDENCE  AND 
TOXICOLOGY. 

Chapman — Medical  Jurisprudence  and 
Toxicology 5 

Golebiewski  and  Bailey — Atlas  of  Dis- 
eases Caused  by  Accidents 17 

Hofmann  and  Peterson— Atlas  of  Legal 
Medicine 16 

NERVOUS  AND  MENTAL 
DISEASES,  ETC. 

Brewer — Manual  of  Insanity 22 

Chapin— Compendium  of  Insanity,    ...  5 
Church  and  Peterson — Nervous  and  Men- 
tal Diseases 5 

Jakob  &  Fisher — Atlas  of  Nervous  System,  17 
Shaw — Essentials  of  Nervous  Diseases  and 

Insanity 15 

NURSING. 

Davis — Obstetric  and  Gynecologic  Nursing,  5 

Griffith— The  Care  of  the  Baby 7 

Hart — Diet  in  Sickness  and  in  Health,   .    .  7 

Meigs — Feeding  in  Early  Infancy 10 

Morten — Nurses'  Dictionary 10 

Stoney — Materia  Medica  for  Nurses,      .    .  13 

Stoney — Practical  Points  in  Nursing,  ...  13 

Stoney — Surgical  Technic  for  Nurses,    .    .  13 

"Watson — Handbook  for  Nurses 14 

OBSTETRICS. 

An  American  Text-Book  of  Obstetrics,    .  2 

Ashton — Essentials  of  Obstetrics 15 

Boisliniere — Obstetric  Accidents,  ....  4 

Dorland — Modern  Obstetrics 6 

Hirst — Text-Book  of  Obstetrics 7 

Norris — Syllabus  of  Obstetrics 10 

Schaeffer  and  Bdgar — Atlas  of  Obstetri- 
cal Diagnosis  and  Treatment 17 

PATHOLOGY. 

An  American  Text-Book  of  Pathology,   .     2 
Durck  and  Hektoen — Atlas  of  Pathologic 

Histology 16 

Kalteyer — Essentials  of  Pathology,    ...    22 
Mallory  and  Wright — Pathological  Tech- 
nique  9 

Senn — Pathology  and  Surgical  Treatment 

of  Tumors 12 

Stengel — Text-Book  of  Pathology,    ...    13 
"Warren — Surgical  Pathology  and  Thera- 
peutics,    14 

PHYSIOLOGY. 

An  American  Text-Book  of  Physiology,  2 

Budgett— Essentials  of  Physiology,   ...  22 

Raymond — Human  Physiology, 11 

Stewart—  Manual  of  Physiology,    ....  13 

PRACTICE  OF  MEDICINE. 
An  American  Year-Book  of  Medicine  and 

Surgery 3 

Anders — Practice  of   Medicine, 4 

Eichhorst — Practice  of  Medicine,  ....     6 
LOCkWOOd — Manual    of    the    Practice    of 

Medicine 9 

Morris — Ess.  of  Practice  of  Medicine,  .    .    15 
Salinger   and  Kalteyer — Modern   Medi- 
cine,     11 

Stevens — Manual  of  Practice  of  Medicine,    13 


SKIN  AND  VENEREAL. 

An  American  Text-Book  of  Genito- 
urinary and  Skin  Diseases 2 

Hyde  and  Montgomery — Syphilis  and  the 
Venereal  Diseases 8 

Martin — Essentials  of  Minor  Surgery, 
Bandaging,  and  Venereal  Diseases,     .    .    15 

Mracek  and  Stelwagon — Atlas  of  Diseases 
of  the  Skin, 16 

Stelwagon — Essentials  of  Diseases  of  the 
Skin 15 

SURGERY. 

An  American  Text-Book  of  Surgery,  .  .  2 
An  American  Year-Book  of  Medicine  and 

Surgery 3 

Beck — Fractures 4 

Beck — Manual  of  Surgical  Asepsis,    ...  4 

Da  Costa — Manual  of  Surgery 5 

International  Text-Book  of  Surgery,  .    .  8 

Keen — Operation  Blank 8 

Keen — The   Surgical    Complications   and 

Sequels  of  Typhoid  Fever 8 

Macdonald — Surgical  Diagnosis  and  Treat- 
ment,    9 

Martin—  Essentials    of    Minor    Surgery, 

Bandaging,  and  Venereal  Diseases,      .    .  15 

Martin — Essentials  of  Surgery 15 

Moore — Orthopedic  Surgery 10 

Nancrede — Principles  of  Surgery,  ....  10 

Pye — Bandaging  and  Surgical  Dressing,     .  11 

Scudder — Treatment  of  Fractures,     ...  12 

Senn — Genito-Urinary  Tuberculosis,  ...  12 

Senn — Practical  Surgery 12 

Senn — Syllabus  of  Surgery 12 

Senn — Pathology  and  Surgical  Treatment 

of  Tumors 12 

Warren — Surgical  Pathology  and  Thera- 
peutics,     14 

Zuckerkandl  and    Da    Costa — Atlas    of 

Operative  Surgery, 16 

URINE  AND  URINARY  DISEASES. 

Ogden — Clinical  Examination  of  the  Urine,  11 
Saundby — Renal  and  Urinary  Diseases,  .  11 
Wolf  —  Handbook       of     Urine-Examina- 


tion  

Wolff —  Essentials 
Urine,      .... 


of     Examination     of 


14 

IS 


MISCELLANEOUS. 

Bastin — Laboratory  Exercises  in  Botany,  .     4 
Golebiewski  and  Bailey— Atlas  of  Dis- 
eases Caused  by  Accidents, 17 

Gould  and  Pyle — Anomalies  and  Curiosi- 
ties of  Medicine 7 

Grafstrom — Massage 7 

Keating — How  to  Examine  for  Life  Insur- 
ance       8 

Saunders'  Medical  Hand-Atlases,  .  .  16,17 
Saunders'  Pocket  Medical  Formulary,  .  .  12 
Saunders'  Question-Compends,  .  .  .  14,15 
Stewart    and    Lawrance — Essentials    of 

Medical  Electricity 15 

Thornton —  Dose-Book    and    Manual    of 

Prescription-Writing 13 

Warwick  and  Tunstall — First  Aid  to  the 
Injured  and  Sick 14 


Books  in  Preparation. 


Jelliffe  arid  Diekman's  Chemistry. 

A  Text-Book  of  Chemistry.  By  Smith  Ely  Jelliffe,  M.  D.,  Ph.D., 
Professor  of  Pharmacology,  College  of  Pharmacy,  New  York;  and 
George  C.  Diekman,  Ph.  G.,  M.  D.,  Professor  of  Theoretical  and 
Applied  Pharmacy,  College  of  Pharmacy,  New  York.  Octavo,  550 
pages,  illustrated. 

Brower's  Manual  of   Insanity. 

A  Practical  Manual  of  Insanity.  By  Daniel  R.  Brower,  M.  D.,  Pro- 
fessor of  Nervous  and  Mental  Diseases,  Rush  Medical  College,  Chicago. 
i2mo  volume  of  425  pages,  illustrated. 

Kalteyer's  Pathology. 

Essentials  of  Pathology.  By  F.  J.  Kalteyer,  M.  D.,  Assistant  Demon- 
strator of  Clinical  Medicine,  Jefferson  Medical  College ;  Pathologist  to 
the  Lying-in  Charity  Hospital  ;  Assistant  Pathologist  to  the  Philadel- 
phia Hospital.      A  New  Volume  in  Saunders'  Question-  Compend  Series. 

Gradle  on  the  Nose,  Throat,  arid  Ear. 

Diseases  of  the  Nose,  Throat,  and  Ear.  By  Henry  Gradle,  M.  D., 
Professor  of  Ophthalmology  and  Otology,  Northwestern  University 
Medical   School,   Chicago.      Octavo,    800   pages,  illustrated. 

Budgett's  Physiology. 

Essentials  of  Physiology.  By  Sidney  P.  Budgett,  M.  D.,  Professor  of 
Physiology,  Washington  University,  St.  Louis,  Mo.  A  New  Volume 
in  Saunders'    Question-  Co??ipend  Series. 

Griffith's  Diseases  of   Children. 

A  Text-Book  of  the  Diseases  of  Children.  By  J.  P.  Crozer  Griffith, 
Clinical  Professor  of  Diseases  of  Children,  University  of  Pennsylvania. 

Galbraith  on  the  Four  Epochs  of  Woman's  Life. 

The  Four  Epochs  of  Woman's  Life  :  A  Study  in  Hygiene.  By  Anna 
M.  Galbraith,  M.  D.,  Fellow  New  York  Academy  of  Medicine;  At- 
tending Physician  Neurologic  Department  New  York  Orthopedic  Hos- 
pital and  Dispensary,  etc.  With  an  Introduction  by  John  H.  Musser, 
M.  D.,  Professor  of  Clinical  Medicine,  University  of  Pennsylvania. 
i2mo  volume  of  about  200  pages. 


JK  f. 


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£3&i 


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